Provider Demographics
NPI:1710477807
Name:PSYCHIATRIC SERVICES AND MEDICATION MANAGEMENT INC
Entity Type:Organization
Organization Name:PSYCHIATRIC SERVICES AND MEDICATION MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:ITVELDT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:509-707-8581
Mailing Address - Street 1:12615 E MISSION AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1047
Mailing Address - Country:US
Mailing Address - Phone:509-707-8581
Mailing Address - Fax:
Practice Address - Street 1:12615 E MISSION AVE STE 310
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1047
Practice Address - Country:US
Practice Address - Phone:509-707-8581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60451837363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty