Basic Information
| Provider Information | |||||||||
| NPI: | 1700867132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVER VALLEY PSYCHOLOGICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 OAKESDALE AVE SW | ||||||||
| Address2: | STE 104 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980575226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252285336 | ||||||||
| FaxNumber: | 4252284540 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 OAKESDALE AVE SW | ||||||||
| Address2: | STE 104 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980575226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252285336 | ||||||||
| FaxNumber: | 4252284540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | CONNOLLY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4252285336 | ||||||||
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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 | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.