Basic Information
| Provider Information | |||||||||
| NPI: | 1699755561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENDRICKSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JOSEPHINE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16040 CHRISTENSEN RD | ||||||||
| Address2: | STE 212 | ||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064315336 | ||||||||
| FaxNumber: | 2064315430 | ||||||||
| Practice Location | |||||||||
| Address1: | 5825 221ST PLACE SE | ||||||||
| Address2: | STE 201 | ||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064315336 | ||||||||
| FaxNumber: | 4253917014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY2719 | WA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.