Provider Demographics
NPI:1326266727
Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON MEDICAL GROUP, INC PS
Other - Org Name:WESTERN WA MEDICAL GROUP DEPT OF PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-259-4041
Mailing Address - Street 1:3525 COLBY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4782
Mailing Address - Country:US
Mailing Address - Phone:425-259-1366
Mailing Address - Fax:425-252-4778
Practice Address - Street 1:3525 COLBY AVE STE 200
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4782
Practice Address - Country:US
Practice Address - Phone:425-259-1366
Practice Address - Fax:425-252-4778
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN WASHINGTON MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601474013103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202207OtherLABOR & INDUSTRY
WA8857639Medicare PIN