1003346594 NPI number — MAGNOLIA PSYCHIATRY, LLC

Table of content: (NPI 1003346594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003346594 NPI number — MAGNOLIA PSYCHIATRY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA PSYCHIATRY, 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:
1003346594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7239
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98008-1239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-467-1000
Provider Business Mailing Address Fax Number:
425-467-0100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12729 NORTHUP WAY STE 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98005-1935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-467-1000
Provider Business Practice Location Address Fax Number:
425-467-0100
Provider Enumeration Date:
06/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PELLICCIARO
Authorized Official First Name:
MARC
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PSYCHIATRIST
Authorized Official Telephone Number:
425-467-1000

Provider Taxonomy Codes

  • Taxonomy code: 2084P0802X , with the licence number:  MD00036813 , 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: MD00036813 . This is a "WASHINGTON STATE MEDICAL LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com