Provider Demographics
NPI:1346274289
Name:PENINSULA PSYCHOLOGICAL CENTER, INC., P.S.
Entity Type:Organization
Organization Name:PENINSULA PSYCHOLOGICAL CENTER, INC., P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:AUTHORIZED OFFICIAL
Authorized Official - Phone:904-605-4983
Mailing Address - Street 1:1191 NW TAHOE LANEPO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383
Mailing Address - Country:US
Mailing Address - Phone:360-698-4860
Mailing Address - Fax:360-698-3849
Practice Address - Street 1:1191 NW TAHOE
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383
Practice Address - Country:US
Practice Address - Phone:360-698-4860
Practice Address - Fax:360-698-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AB16715Medicare ID - Type Unspecified
PTANGAB16715Medicare PIN