Provider Demographics
NPI:1962674010
Name:FEDERAL WAY PSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:FEDERAL WAY PSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALYSA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RUDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:253-874-5319
Mailing Address - Street 1:801 S 336TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6310
Mailing Address - Country:US
Mailing Address - Phone:253-874-5319
Mailing Address - Fax:253-838-5586
Practice Address - Street 1:801 S 336TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6310
Practice Address - Country:US
Practice Address - Phone:253-874-5319
Practice Address - Fax:253-838-5586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPSY1268103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG00010846668Medicare PIN