Provider Demographics
NPI:1679970925
Name:PACIFIC MENTAL HEALTH
Entity Type:Organization
Organization Name:PACIFIC MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMHC
Authorized Official - Phone:206-658-3920
Mailing Address - Street 1:230 NW 201ST ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-2012
Mailing Address - Country:US
Mailing Address - Phone:206-658-3920
Mailing Address - Fax:
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:SUITE A1
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3197
Practice Address - Country:US
Practice Address - Phone:206-658-3920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60500437251S00000X
WALH60320548251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health