1205289360 NPI number — SUNRISE PSYCHOLOGY, LLC

Table of content: (NPI 1205289360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205289360 NPI number — SUNRISE PSYCHOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNRISE PSYCHOLOGY, LLC
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:
1205289360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4113 BRIDGEPORT WAY W
Provider Second Line Business Mailing Address:
STE C1
Provider Business Mailing Address City Name:
UNIVERSITY PLACE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98466-4325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-987-6825
Provider Business Mailing Address Fax Number:
253-590-0875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4113 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
STE C1
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-987-6825
Provider Business Practice Location Address Fax Number:
253-590-0875
Provider Enumeration Date:
07/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BREIKSS
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
THERAPIST / OWNER
Authorized Official Telephone Number:
253-987-6825

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH 60231168 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2023189 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com