1316037302 NPI number — PACIFIC COUNSELING CLINIC, INC.

Table of content: (NPI 1316037302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316037302 NPI number — PACIFIC COUNSELING CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC COUNSELING CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316037302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10049 KITSAP MALL BLVD NW
Provider Second Line Business Mailing Address:
STE. 203
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-8903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-307-8700
Provider Business Mailing Address Fax Number:
360-692-6458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10049 KITSAP MALL BLVD NW
Provider Second Line Business Practice Location Address:
STE. 203
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-307-8700
Provider Business Practice Location Address Fax Number:
360-692-6458
Provider Enumeration Date:
10/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KNUDSON
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-307-8700

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LW00008740 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: LW00005406 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: LF00001317 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)