MEDICARE: GEORGE WILLIAM RECKNAGEL JR. PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PY00002604	WA

General Provider Information

NPI Number	:	1114031176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE WILLIAM RECKNAGEL JR. PH.D.

Provider Business Mailing Address
First Line	:	4819 NE 93RD ST
Second Line	:	P.O. BOX 15153
City	:	SEATTLE
State	:	WA
Zip	:	98115-3930
Country	:	US
Telephone Number	:	206-818-4179
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 LAKE BELLEVUE DR STE 217
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98005-2454
Country	:	US
Telephone Number	:	206-818-4179
Fax Number	:	206-729-1479

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	12/13/2016

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