Provider Demographics
NPI:1821607417
Name:DENNIS, EDMOND IV (MSP)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:
Last Name:DENNIS
Suffix:IV
Gender:M
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 SW 320TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-2292
Mailing Address - Country:US
Mailing Address - Phone:253-289-6099
Mailing Address - Fax:253-231-7251
Practice Address - Street 1:3430 SW 320TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-2292
Practice Address - Country:US
Practice Address - Phone:253-289-6099
Practice Address - Fax:253-231-7251
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61416353106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist