Provider Demographics
NPI:1427571652
Name:SECRIST, CORY DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:DAVID
Last Name:SECRIST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16731 8TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5013
Mailing Address - Country:US
Mailing Address - Phone:206-788-7579
Mailing Address - Fax:
Practice Address - Street 1:1417 NW 54TH ST STE 372
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3575
Practice Address - Country:US
Practice Address - Phone:206-788-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60588923103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist