Basic Information
| Provider Information | |||||||||
| NPI: | 1396831038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOVE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3685 MEERKERK LANE | ||||||||
| Address2: | |||||||||
| City: | GREENBANK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602223057 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3322 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253497289 | ||||||||
| FaxNumber: | 4253497288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | RC00024124 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | RC00024142 | 05 | WA | MEDICAID |