Provider Demographics
NPI:1306183801
Name:GRANDE RONDE PSYCHIATRIC SERVICES, PC
Entity Type:Organization
Organization Name:GRANDE RONDE PSYCHIATRIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:TRUDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-477-3298
Mailing Address - Street 1:1994 S BAGLEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7454
Mailing Address - Country:US
Mailing Address - Phone:360-477-3298
Mailing Address - Fax:360-452-9584
Practice Address - Street 1:435 W BELL ST
Practice Address - Street 2:STE. B-1
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-2916
Practice Address - Country:US
Practice Address - Phone:360-477-3298
Practice Address - Fax:360-452-9584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60053143261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0265930OtherLABOR AND INDUSTRIES
OR113092Medicaid
WA0265930OtherLABOR AND INDUSTRIES