MEDICARE: PSYCHOLOGY FOR MEANINGFUL CHANGE, P.S.

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	PY00002451	WA

General Provider Information

NPI Number	:	1649464876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOLOGY FOR MEANINGFUL CHANGE, P.S.

Provider Business Mailing Address
First Line	:	3429 FREMONT PL N
Second Line	:	SUITE 311
City	:	SEATTLE
State	:	WA
Zip	:	98103-8660
Country	:	US
Telephone Number	:	206-914-1444
Fax Number	:	806-214-1444

Provider Business Practice Location Address
First Line	:	3429 FREMONT PL N
Second Line	:	SUITE 311
City	:	SEATTLE
State	:	WA
Zip	:	98103-8660
Country	:	US
Telephone Number	:	206-914-1444
Fax Number	:	806-214-1444

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BONNIE WOLKENSTEIN
Credential	:	PH.D.
Telephone Number	:	206-914-1444

Provider Enumeration Date	:	08/30/2007
Last Update Date	:	03/18/2008

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