=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114462645
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ARIEL PAULENICH PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2016
-----------------------------------------------------
Last Update Date | 07/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2413 MAIN ST STE 204
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98248-8827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-296-3989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3134
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98248-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-296-3989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY 60616293
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------