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General NPI Number Information
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NPI Number | 1104267558
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Entity Type | Organization
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Legal Business Name | OLYMPIA PSYCHOTHERAPY INC
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Dates
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Enumeration Date | 07/15/2013
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Last Update Date | 07/15/2013
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Provider Practice Location Address
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Address Line | 1408 STATE AVE NE STE 110
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City | OLYMPIA
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State | WA
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Zip | 98506-4481
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Country | US
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Telephone | 360-352-3034
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Fax | 360-352-3035
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Provider Business Mailing Address
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Address Line | 1408 STATE AVE NE STE 110
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City | OLYMPIA
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State | WA
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Zip | 98506-4481
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Country | US
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Telephone | 360-352-3034
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Fax | 360-352-3035
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Authorized Official
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Title or Position | PRESIDENT/PROGRAM DIRECTOR
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Name | JENNIFER GOODWIN
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Credential | MA LMHC CDP
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Telephone | 360-352-3034
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 34139400
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License Number State | WA
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