Provider Demographics
NPI:1629781067
Name:MARK ELLESTAD, MD - PSYCHIATRIC SERVICES, PLLC
Entity Type:Organization
Organization Name:MARK ELLESTAD, MD - PSYCHIATRIC SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLESTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-659-1750
Mailing Address - Street 1:3417 EVANSTON AVE N STE 306
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8967
Mailing Address - Country:US
Mailing Address - Phone:206-659-1750
Mailing Address - Fax:206-752-8505
Practice Address - Street 1:3417 EVANSTON AVE N STE 306
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8967
Practice Address - Country:US
Practice Address - Phone:206-251-4014
Practice Address - Fax:206-752-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-30
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty