Provider Demographics
NPI:1013123629
Name:PSYCHIATRIC AND COUNSELING SERVICES OF OLYMPIA, PS
Entity type:Organization
Organization Name:PSYCHIATRIC AND COUNSELING SERVICES OF OLYMPIA, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:STARR
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:360-709-3332
Mailing Address - Street 1:2114 CATON WAY SW # 201
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-1105
Mailing Address - Country:US
Mailing Address - Phone:360-709-3332
Mailing Address - Fax:360-709-3336
Practice Address - Street 1:2114 CATON WAY SW # 201
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1105
Practice Address - Country:US
Practice Address - Phone:360-709-3332
Practice Address - Fax:360-709-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003632363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8866479Medicare PIN