1992782015 NPI number — CRESTVIEW PSYCHOLOGICAL SERVICES, P.S.

Table of content: (NPI 1992782015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992782015 NPI number — CRESTVIEW PSYCHOLOGICAL SERVICES, P.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRESTVIEW PSYCHOLOGICAL SERVICES, P.S.
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:
1992782015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 GROVER ST
Provider Second Line Business Practice Location Address:
SUITE D-1
Provider Business Practice Location Address City Name:
LYNDEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98264-1539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-398-8217
Provider Business Practice Location Address Fax Number:
360-354-5399
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BRINKMAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-398-8127

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY00001993 , 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)





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