Provider Demographics
NPI:1407406671
Name:PHILLABAUM, MCKENNA E
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:E
Last Name:PHILLABAUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4568 34TH AVE W
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98199-1133
Mailing Address - Country:US
Mailing Address - Phone:253-970-6697
Mailing Address - Fax:
Practice Address - Street 1:1817 QUEEN ANNE AVE N STE 204
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-2876
Practice Address - Country:US
Practice Address - Phone:206-765-8265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61132399106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty