Basic Information
| Provider Information | |||||||||
| NPI: | 1437447208 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SILVERDALE PSYCHIATRIC SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97115 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984970115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2539846774 | ||||||||
| Practice Location | |||||||||
| Address1: | 7191 WAGNER WAY NW | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | GIG HARBOR | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983356909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535148076 | ||||||||
| FaxNumber: | 2535148078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 07/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | CAROLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 2535887911 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LH00003850 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | LH00003850 | 01 | WA | CAROLE'S MEDICAL LICENSE | OTHER |