Provider Demographics
NPI:1568671766
Name:WENDELL STREET PSYCHIATRIC LLC
Entity Type:Organization
Organization Name:WENDELL STREET PSYCHIATRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKKI
Authorized Official - Middle Name:KING
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-455-4135
Mailing Address - Street 1:225 WENDELL ST
Mailing Address - Street 2:STE B
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4835
Mailing Address - Country:US
Mailing Address - Phone:907-455-4135
Mailing Address - Fax:907-455-4115
Practice Address - Street 1:225 WENDELL ST
Practice Address - Street 2:STE B
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4835
Practice Address - Country:US
Practice Address - Phone:907-455-4135
Practice Address - Fax:907-455-4115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK39212084P0800X, 2084P0804X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty