Basic Information
| Provider Information | |||||||||
| NPI: | 1184796799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUBLIC HOSPITAL DISTRICT NO. 2 | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERGREEN HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11610 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984116610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258991000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12040 NE 128TH ST | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980343013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258991000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 04/02/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YAMADA | ||||||||
| AuthorizedOfficialFirstName: | CHRISSY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4258992600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PUBLIC HOSPITAL DISTRICT NO. 2 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.