Provider Demographics
NPI:1912310103
Name:PUGET SOUND PSYCHOTHERAPY
Entity Type:Organization
Organization Name:PUGET SOUND PSYCHOTHERAPY
Other - Org Name:PUGET SOUND PSYCHOTHERAPY, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-571-3069
Mailing Address - Street 1:3123 FAIRVIEW AVE E STE W
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3051
Mailing Address - Country:US
Mailing Address - Phone:206-571-3069
Mailing Address - Fax:206-569-0010
Practice Address - Street 1:3123 FAIRVIEW AVE E STE W
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3051
Practice Address - Country:US
Practice Address - Phone:206-571-3069
Practice Address - Fax:206-569-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60071756101YM0800X
WALF60354195106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty