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General NPI Number Information
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NPI Number | 1871651042
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE PSYCHIATRIC CENTER
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1400 TALBOT RD S SUITE 203
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City | RENTON
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State | WA
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Zip | 98055-4291
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Country | US
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Telephone | 425-235-7383
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Fax | 425-228-2169
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Provider Business Mailing Address
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Address Line | 1400 TALBOT RD S SUITE 203
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City | RENTON
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State | WA
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Zip | 98055-4291
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Country | US
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Telephone | 425-235-7383
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Fax | 425-228-2169
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN EDWARD DUNNE
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Credential | M.D.
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Telephone | 425-235-7383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 14418
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License Number State | WA
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