Provider Demographics
NPI:1053645754
Name:PACIFIC THERAPY GROUP, PLLC
Entity Type:Organization
Organization Name:PACIFIC THERAPY GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:425-454-7541
Mailing Address - Street 1:1601 116TH AVE NE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3010
Mailing Address - Country:US
Mailing Address - Phone:425-454-7541
Mailing Address - Fax:425-454-1142
Practice Address - Street 1:1601 116TH AVE NE
Practice Address - Street 2:SUITE 114
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3010
Practice Address - Country:US
Practice Address - Phone:425-454-7541
Practice Address - Fax:425-454-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health