Provider Demographics
NPI:1104569623
Name:RIVENDELL PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:RIVENDELL PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLINCEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:360-255-8260
Mailing Address - Street 1:410 W BAKERVIEW ROAD
Mailing Address - Street 2:STE 110, OFFICE 148
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226
Mailing Address - Country:US
Mailing Address - Phone:360-255-8260
Mailing Address - Fax:
Practice Address - Street 1:410 W BAKERVIEW ROAD
Practice Address - Street 2:STE 110, OFFICE 148
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226
Practice Address - Country:US
Practice Address - Phone:360-255-8260
Practice Address - Fax:360-262-6221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty