=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790675122
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC NORTHWEST PSYCHOLOGICAL SERVICES AND CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2025
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4428 65TH AVE NE
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98516-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-997-9974
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4428 65TH AVE NE
-----------------------------------------------------
City | OLYMPIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98516-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-615-3950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | BENJAMIN TRACHIK
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 360-625-3950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------