=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861824211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY OF WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2013
-----------------------------------------------------
Last Update Date | 08/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3920 15TH AVE NE UW MAILSTOP 351635
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98195-1635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-543-6511
-----------------------------------------------------
Fax | 206-616-8367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1959 NE PACIFIC ST UW MAILSTOP 351635
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98195-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-543-6511
-----------------------------------------------------
Fax | 206-616-8367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. COREY N FAGAN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 206-543-6511
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | H-128
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------