Provider Demographics
NPI:1518979434
Name:MOUNTAINSIDE PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:MOUNTAINSIDE PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:HUGHES
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:MN, ARNP
Authorized Official - Phone:253-460-9414
Mailing Address - Street 1:10209 BRIDGEPORT WAY SW
Mailing Address - Street 2:SUITE D 10
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2326
Mailing Address - Country:US
Mailing Address - Phone:253-460-9414
Mailing Address - Fax:253-460-0999
Practice Address - Street 1:10209 BRIDGEPORT WAY SW
Practice Address - Street 2:SUITE D 10
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2320
Practice Address - Country:US
Practice Address - Phone:253-460-9414
Practice Address - Fax:253-460-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8874644Medicare PIN