Provider Demographics
NPI:1295276251
Name:PIIQ SPACE PC
Entity type:Organization
Organization Name:PIIQ SPACE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANIVONG
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:RATTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMHC, LPC, NCC
Authorized Official - Phone:206-409-0885
Mailing Address - Street 1:4310 89TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-4132
Mailing Address - Country:US
Mailing Address - Phone:206-409-0885
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE STE 701
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3508
Practice Address - Country:US
Practice Address - Phone:206-409-0885
Practice Address - Fax:206-274-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty