MEDICARE: CRESTVIEW PSYCHOLOGICAL SERVICES, 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	PY00001993	WA

General Provider Information

NPI Number	:	1992782015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTVIEW PSYCHOLOGICAL SERVICES, P.S.

Provider Business Mailing Address
First Line	:	PO BOX 331
Second Line	:
City	:	LYNDEN
State	:	WA
Zip	:	98264-0331
Country	:	US
Telephone Number	:	360-398-8127
Fax Number	:	360-354-5399

Provider Business Practice Location Address
First Line	:	1610 GROVER ST
Second Line	:	SUITE D-1
City	:	LYNDEN
State	:	WA
Zip	:	98264-1539
Country	:	US
Telephone Number	:	360-398-8217
Fax Number	:	360-354-5399

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIEL DALE BRINKMAN
Credential	:	PSY.D.
Telephone Number	:	360-398-8127

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	04/21/2022

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