Provider Demographics
NPI:1972160265
Name:PAULENICH MENTAL HEALTH PLLC
Entity Type:Organization
Organization Name:PAULENICH MENTAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAULENICH
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:360-296-3989
Mailing Address - Street 1:PO BOX 3134
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-3134
Mailing Address - Country:US
Mailing Address - Phone:360-296-3989
Mailing Address - Fax:
Practice Address - Street 1:2413 MAIN ST STE 204
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-8827
Practice Address - Country:US
Practice Address - Phone:360-296-3989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-22
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2072909Medicaid