Basic Information
Provider Information | |||||||||
NPI: | 1780774950 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUND MENTAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6400 SOUTHCENTER BLVD | ||||||||
Address2: |   | ||||||||
City: | TUKWILA | ||||||||
State: | WA | ||||||||
PostalCode: | 981882547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069012000 | ||||||||
FaxNumber: | 2069012010 | ||||||||
Practice Location | |||||||||
Address1: | 6400 SOUTHCENTER BLVD | ||||||||
Address2: |   | ||||||||
City: | TUKWILA | ||||||||
State: | WA | ||||||||
PostalCode: | 981882547 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2069012000 | ||||||||
FaxNumber: | 2069012010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 04/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EISENHAUER | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2063022200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CFO, MBA, MA | ||||||||
NPICertificationDate: | 04/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X |   | WA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X |   | WA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM2500X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QM0801X |   | WA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 1045651 | 01 | WA | PROVIDER ONE | OTHER | 1982800 | 05 | WA |   | MEDICAID |