1033525423 NPI number — MAHANAIM PSYCHOLOGY SERVICES, PLLC

Table of content: (NPI 1033525423)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033525423 NPI number — MAHANAIM PSYCHOLOGY SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAHANAIM PSYCHOLOGY SERVICES, PLLC
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:
1033525423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEER PARK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99006-2110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-276-5644
Provider Business Mailing Address Fax Number:
509-276-5644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 W CRAWFORD ST STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006-5356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-276-5644
Provider Business Practice Location Address Fax Number:
509-780-4394
Provider Enumeration Date:
07/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BROST
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT OF CORPORATION/PROVIDER
Authorized Official Telephone Number:
509-276-5644

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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