Basic Information
| Provider Information | |||||||||
| NPI: | 1427384411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUBLIC HOSPITAL DISTRICT #1 OF KING COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VMC WASHINGTON NEUROSCIENCE INSTITUTE-PSYCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34876 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565412 | ||||||||
| FaxNumber: | 4256564096 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 TALBOT RD S | ||||||||
| Address2: | STE 104 | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565566 | ||||||||
| FaxNumber: | 4256565567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2009 | ||||||||
| LastUpdateDate: | 10/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | GRINNELL | ||||||||
| AuthorizedOfficialFirstName: | JEANNINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4252283440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | H-155 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 7136310 | 05 | WA | MEDICAID |