Provider Demographics
NPI:1477760197
Name:PROVAIL
Entity Type:Organization
Organization Name:PROVAIL
Other - Org Name:PROVAIL THERAPEUTIC AND ASSISTIVE TECHNOLOGY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HATZENBELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-363-7303
Mailing Address - Street 1:12550 AURORA AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8036
Mailing Address - Country:US
Mailing Address - Phone:206-363-7303
Mailing Address - Fax:206-826-0181
Practice Address - Street 1:12550 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8036
Practice Address - Country:US
Practice Address - Phone:206-363-7303
Practice Address - Fax:206-826-0181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASI00004391235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA55-0174569OtherLABOR AND INDUSTRIES
WA7070949-8347395Medicaid
WA7681083-8464992Medicaid
WA7368087OtherAETNA CLINIC NUMBER
WA7070949-8347429Medicaid
WA7681083-8415291Medicaid
WA397572001OtherGROUP HEALTH PROVIDER NUM
WA=========-8519COOtherREGENCE SPEECH THERAPY
WA=========OtherPREMERA BLUE CROSS
WA=========-3671WYOtherREGENCE SPEECH THERAPY
WA7368087OtherAETNA CLINIC NUMBER
WA=========OtherCIGNA PROVIDER NUMBER
WA7070949-8347395Medicaid
WA7681083-8415291Medicaid
WA55-0174569OtherLABOR AND INDUSTRIES
WA7070949-8347429Medicaid
WA397572001OtherGROUP HEALTH PROVIDER NUM
VA=========-0563FAOtherREGENCE SPEECH THERAPY
WA7681083-8464992Medicaid