Provider Demographics
NPI:1225883986
Name:SEYFRIED, JUSTIN ILLICK
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ILLICK
Last Name:SEYFRIED
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 244TH ST SW APT W206
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-7535
Mailing Address - Country:US
Mailing Address - Phone:206-390-2848
Mailing Address - Fax:
Practice Address - Street 1:11415 NE 128TH ST STE 40
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6315
Practice Address - Country:US
Practice Address - Phone:425-307-1815
Practice Address - Fax:425-533-2597
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician