Provider Demographics
NPI:1316037302
Name:PACIFIC COUNSELING CLINIC, INC.
Entity Type:Organization
Organization Name:PACIFIC COUNSELING CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-307-8700
Mailing Address - Street 1:10049 KITSAP MALL BLVD NW
Mailing Address - Street 2:STE. 203
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8903
Mailing Address - Country:US
Mailing Address - Phone:360-307-8700
Mailing Address - Fax:360-692-6458
Practice Address - Street 1:10049 KITSAP MALL BLVD NW
Practice Address - Street 2:STE. 203
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8903
Practice Address - Country:US
Practice Address - Phone:360-307-8700
Practice Address - Fax:360-692-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000087401041C0700X
WALW000054061041C0700X
WALF00001317106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty