Provider Demographics
NPI:1669830774
Name:BRAIN HEALTH NORTHWEST
Entity Type:Organization
Organization Name:BRAIN HEALTH NORTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:206-321-1017
Mailing Address - Street 1:219 1ST AVE S
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2575
Mailing Address - Country:US
Mailing Address - Phone:206-321-1017
Mailing Address - Fax:206-641-3246
Practice Address - Street 1:219 1ST AVE S
Practice Address - Street 2:SUITE 310
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2575
Practice Address - Country:US
Practice Address - Phone:206-321-1017
Practice Address - Fax:206-641-3246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL60528100101YP2500X
WA1613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty