Basic Information
| Provider Information | |||||||||
| NPI: | 1982966370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNRISE PSYCHIATRIC AND PROFESSIONAL SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 811 MADISON ST | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982034543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254935800 | ||||||||
| FaxNumber: | 4254935801 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 MADISON | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982034543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254935800 | ||||||||
| FaxNumber: | 4254935801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 02/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOWERS | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4253745888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 225 | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1981554 | 05 | WA | MEDICAID |