Provider Demographics
NPI:1871651042
Name:SOUTHLAKE PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:SOUTHLAKE PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DUNNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-235-7383
Mailing Address - Street 1:1400 TALBOT RD S
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-4291
Mailing Address - Country:US
Mailing Address - Phone:425-235-7383
Mailing Address - Fax:425-228-2169
Practice Address - Street 1:1400 TALBOT RD S
Practice Address - Street 2:SUITE 203
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-4291
Practice Address - Country:US
Practice Address - Phone:425-235-7383
Practice Address - Fax:425-228-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA144182084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0191845OtherL & I
WA1228600Medicaid