Provider Demographics
NPI:1407294465
Name:CITY UNIVERSITY
Entity Type:Organization
Organization Name:CITY UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:206-239-4762
Mailing Address - Street 1:2313 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3841
Mailing Address - Country:US
Mailing Address - Phone:253-503-9035
Mailing Address - Fax:
Practice Address - Street 1:2313 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3841
Practice Address - Country:US
Practice Address - Phone:253-503-9035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health