Provider Demographics
NPI:1104267558
Name:OLYMPIA PSYCHOTHERAPY INC
Entity type:Organization
Organization Name:OLYMPIA PSYCHOTHERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA LMHC CDP
Authorized Official - Phone:360-352-3034
Mailing Address - Street 1:1408 STATE AVE NE STE 110
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4481
Mailing Address - Country:US
Mailing Address - Phone:360-352-3034
Mailing Address - Fax:360-352-3035
Practice Address - Street 1:1408 STATE AVE NE STE 110
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4481
Practice Address - Country:US
Practice Address - Phone:360-352-3034
Practice Address - Fax:360-352-3035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA34139400251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health