1518231893 NPI number — SOUTH WHIDBEY PSYCHOLOGICAL SERVICES, PLLC

Table of content: (NPI 1518231893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518231893 NPI number — SOUTH WHIDBEY PSYCHOLOGICAL SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH WHIDBEY PSYCHOLOGICAL 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:
6
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:
1518231893
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 439
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98236-0439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-341-4484
Provider Business Mailing Address Fax Number:
866-627-8142

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11042 SR 525
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98236-8600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-341-4484
Provider Business Practice Location Address Fax Number:
866-627-8142
Provider Enumeration Date:
03/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
COLBY
Authorized Official First Name:
FAULDER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/SOLE MEMBER
Authorized Official Telephone Number:
360-341-4484

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PY 00001909 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: PY 00001909 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TF0200X , with the licence number: PY 00001909 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PY 00001909 , 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: DT0357 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2017481 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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