Provider Demographics
NPI:1336613553
Name:VIVID PSYCHIATRY LLC
Entity Type:Organization
Organization Name:VIVID PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGINNIS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:937-479-3406
Mailing Address - Street 1:20606 SE 258TH PL
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-6156
Mailing Address - Country:US
Mailing Address - Phone:937-479-3406
Mailing Address - Fax:877-894-5104
Practice Address - Street 1:22443 SE 240TH ST STE 202
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-5879
Practice Address - Country:US
Practice Address - Phone:937-479-3406
Practice Address - Fax:877-894-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP60729876OtherLICENSE