Basic Information
| Provider Information | |||||||||
| NPI: | 1629120159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY PSYCHIATRIC CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11000 LAKE CITY WAY NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981256748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064613614 | ||||||||
| FaxNumber: | 2066340094 | ||||||||
| Practice Location | |||||||||
| Address1: | 11000 LAKE CITY WAY NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981256748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064613614 | ||||||||
| FaxNumber: | 2066340094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | SYMONS | ||||||||
| AuthorizedOfficialFirstName: | KELCEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMIN SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2065452387 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 035 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | 17087600 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 17087500 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 251S00000X | 117700 | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1981802 | 05 | WA | MEDICAID | 1992882 | 05 | WA | MEDICAID | 1992890 | 05 | WA | MEDICAID | 1992650 | 05 | WA | MEDICAID | 1992668 | 05 | WA | MEDICAID | 1992874 | 05 | WA | MEDICAID |