Provider Demographics
NPI:1841811783
Name:IREDALE PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:IREDALE PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TRUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:IREDALE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-991-0134
Mailing Address - Street 1:1804 SE 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-3474
Mailing Address - Country:US
Mailing Address - Phone:360-991-0134
Mailing Address - Fax:360-991-0154
Practice Address - Street 1:1804 SE 170TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3474
Practice Address - Country:US
Practice Address - Phone:360-991-0134
Practice Address - Fax:360-991-0154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-01
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841811783OtherTYPE II NPI
1770649402OtherNPI
WAPY00003097OtherWA STATE LICENSE