Provider Demographics
NPI:1427557610
Name:SUNRISE FAMILY THERAPY AFFORDABLE FAMILY THERAPY
Entity Type:Organization
Organization Name:SUNRISE FAMILY THERAPY AFFORDABLE FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT MHP CHT
Authorized Official - Phone:253-777-9782
Mailing Address - Street 1:17404 MERIDIAN E # F131
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-6234
Mailing Address - Country:US
Mailing Address - Phone:253-777-9782
Mailing Address - Fax:
Practice Address - Street 1:3911 9TH ST SW # A211-212
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5946
Practice Address - Country:US
Practice Address - Phone:253-777-9782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG60662041106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1164829289Medicaid