Healthcare Provider Details

I. General information

NPI: 1609601384
Provider Name (Legal Business Name): PSYCHE WELLBEING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 NE PARK PLAZA DR STE 200
VANCOUVER WA
98684-5871
US

IV. Provider business mailing address

PO BOX 699
CAMAS WA
98607-0699
US

V. Phone/Fax

Practice location:
  • Phone: 360-903-1829
  • Fax: 360-991-0337
Mailing address:
  • Phone: 360-903-1829
  • Fax: 360-991-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOVEL BROQUEZA
Title or Position: PRESIDENT
Credential: DNP
Phone: 360-903-1829