=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265858534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR SYSTEMATIC THERAPY AND RESEARCH SERCIVES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2014
-----------------------------------------------------
Last Update Date | 03/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 402 S 333RD ST SUITE 121
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-6309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-929-1543
-----------------------------------------------------
Fax | 866-311-9279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 S 333RD ST SUITE 121
-----------------------------------------------------
City | FEDERAL WAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98003-6309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-929-1543
-----------------------------------------------------
Fax | 866-311-9279
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSOCIATE DIRECTOR
-----------------------------------------------------
Name | MELISSA ANN BYRD
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 253-929-1543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PY00002013
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LH60323507
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------