Basic Information
| Provider Information | |||||||||
| NPI: | 1649918673 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNRISE SERVICES INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2569 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982130569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252124200 | ||||||||
| FaxNumber: | 4252124220 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982034543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252124200 | ||||||||
| FaxNumber: | 4252124220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2022 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | TAGEANT | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4252124200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.