Basic Information
Provider Information | |||||||||
NPI: | 1972610418 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEMC MENTAL HEALTH CONSULTATION SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 909 N BROADWAY | ||||||||
Address2: | PBO CREDENTIALING | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253170264 | ||||||||
FaxNumber: | 4253170291 | ||||||||
Practice Location | |||||||||
Address1: | 1321 COLBY AVE | ||||||||
Address2: |   | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011665 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252613968 | ||||||||
FaxNumber: | 4252613967 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 09/23/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOBAYASHI | ||||||||
AuthorizedOfficialFirstName: | JOYCE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIR REVENUE CYCLE MGMT NWSA | ||||||||
AuthorizedOfficialTelephone: | 4253170186 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X |   | WA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084A0401X |   | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine |
ID Information
ID | Type | State | Issuer | Description | 7075161 | 05 | WA |   | MEDICAID | 7128150 | 05 | WA |   | MEDICAID |