1619354636 NPI number — DR. MELISSA A KNOWLTON-PATHEAL PSYD

Table of content: DR. MELISSA A KNOWLTON-PATHEAL PSYD (NPI 1619354636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619354636 NPI number — DR. MELISSA A KNOWLTON-PATHEAL PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNOWLTON-PATHEAL
Provider First Name:
MELISSA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KNOWLTON
Provider Other First Name:
MELISSA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619354636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N MORAIN ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-2905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-543-7253
Provider Business Mailing Address Fax Number:
509-735-8535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N MORAIN ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-2905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-543-7253
Provider Business Practice Location Address Fax Number:
509-735-8535
Provider Enumeration Date:
04/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PY60472709 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 4062 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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