Provider Demographics
NPI:1598349631
Name:VANGUARD PSYCHIATRY LLC
Entity Type:Organization
Organization Name:VANGUARD PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DEFILIPPO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ARNP
Authorized Official - Phone:650-753-1193
Mailing Address - Street 1:4935 STATE ROUTE 20
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-9701
Mailing Address - Country:US
Mailing Address - Phone:650-753-1193
Mailing Address - Fax:
Practice Address - Street 1:221 W PATISON ST STE 203A
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9751
Practice Address - Country:US
Practice Address - Phone:908-509-7764
Practice Address - Fax:360-369-6722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2041287Medicaid