Provider Demographics
NPI:1801130976
Name:WASHINGTON STATE PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:WASHINGTON STATE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVELLANA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:425-387-6972
Mailing Address - Street 1:3224 75TH DR NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-6804
Mailing Address - Country:US
Mailing Address - Phone:425-387-6972
Mailing Address - Fax:
Practice Address - Street 1:5105 200TH ST SW STE 100
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6397
Practice Address - Country:US
Practice Address - Phone:425-387-6972
Practice Address - Fax:425-377-0701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60014648103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8874870Medicare PIN