COMMUNITY PSYCHIATRIC CLINIC INC

Provider Demographics

• NPI: 1629120159
• Name: COMMUNITY PSYCHIATRIC CLINIC INC
• Entity Type: Organization
• Organization Name: COMMUNITY PSYCHIATRIC CLINIC INC
• Authorized Official - Title/Position: ADMIN SUPERVISOR
• Authorized Official - Prefix: MISS
• Authorized Official - First Name: KELCEY
• Authorized Official - Last Name: SYMONS
• Authorized Official - Phone: 206-545-2387
• Mailing Address - Street 1: 11000 LAKE CITY WAY NE
• Mailing Address - Street 2: SUITE 200
• Mailing Address - City: SEATTLE
• Mailing Address - State: WA
• Mailing Address - Zip Code: 98125-6748
• Mailing Address - Country: US
• Mailing Address - Phone: 206-461-3614
• Mailing Address - Fax: 206-634-0094
• Practice Address - Street 1: 11000 LAKE CITY WAY NE
• Practice Address - Street 2: SUITE 200
• Practice Address - City: SEATTLE
• Practice Address - State: WA
• Practice Address - Zip Code: 98125-6748
• Practice Address - Country: US
• Practice Address - Phone: 206-461-3614
• Practice Address - Fax: 206-634-0094
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-01-17
• Last Update Date: 2018-09-26

Provider Licenses

State	License ID	Taxonomies
WA	117700	251S00000X
WA	035	261QM0801X
WA	17087600	261QR0405X
WA	17087500	261QR0405X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	251S00000X	Agencies	Community/Behavioral Health
No	261QM0801X	Ambulatory Health Care Facilities	Clinic/Center	Mental Health (Including Community Mental Health Center)
No	261QR0405X	Ambulatory Health Care Facilities	Clinic/Center	Rehabilitation, Substance Use Disorder

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	1981802	Medicaid
WA	1992882	Medicaid
WA	1992890	Medicaid
WA	1992650	Medicaid
WA	1992668	Medicaid
WA	1992874	Medicaid
WA	G217125900	Medicare PIN
WA	G217126200	Medicare PIN
WA	217126200	Medicare ID - Type Unspecified	CPC-NORTHGATE
WA	217126300	Medicare ID - Type Unspecified	CPC-WALLINGFORD HOUSE
WA	1992668	Medicaid
WA	1992890	Medicaid
WA	G217125700	Medicare PIN
WA	G217126300	Medicare PIN
WA	217126100	Medicare ID - Type Unspecified	CPC-EL REY
WA	1992874	Medicaid
WA	1981802	Medicaid
WA	217125900	Medicare ID - Type Unspecified	CPC-CASCADE HALL
WA	G000148200	Medicare PIN
WA	G000148200	Medicare PIN