Provider Demographics
NPI:1164638938
Name:LIN, ELLEN K (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:K
Last Name:LIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 161ST AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3858
Mailing Address - Country:US
Mailing Address - Phone:206-790-4908
Mailing Address - Fax:
Practice Address - Street 1:8301 161ST AVE NE
Practice Address - Street 2:SUITE 300
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3858
Practice Address - Country:US
Practice Address - Phone:206-790-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY2815103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
020782109OtherFEDERAL TAX ID
WA486617100000OtherPREMERA BLUE CROSS