=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649464876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOLOGY FOR MEANINGFUL CHANGE, P.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2007
-----------------------------------------------------
Last Update Date | 03/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3429 FREMONT PL N SUITE 311
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-8660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-914-1444
-----------------------------------------------------
Fax | 806-214-1444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3429 FREMONT PL N SUITE 311
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98103-8660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-914-1444
-----------------------------------------------------
Fax | 806-214-1444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BONNIE WOLKENSTEIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 206-914-1444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY00002451
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------