Basic Information
| Provider Information | |||||||||
| NPI: | 1649407644 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENIOR PSYCHOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9340 NE 76TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986623721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602534912 | ||||||||
| FaxNumber: | 3602535170 | ||||||||
| Practice Location | |||||||||
| Address1: | 9340 NE 76TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986623721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602534912 | ||||||||
| FaxNumber: | 3602535170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2009 | ||||||||
| LastUpdateDate: | 06/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | AGNOR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3602534912 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PY00001983 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.