Provider Demographics
NPI:1114254729
Name:PUGET SOUND PSYCHIATRIC CENTER, PS
Entity type:Organization
Organization Name:PUGET SOUND PSYCHIATRIC CENTER, PS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SYED
Authorized Official - Middle Name:JAMAL
Authorized Official - Last Name:MUSTAFA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-806-5021
Mailing Address - Street 1:10634 E RIVERSIDE DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3758
Mailing Address - Country:US
Mailing Address - Phone:425-806-5021
Mailing Address - Fax:425-486-3949
Practice Address - Street 1:10634 E RIVERSIDE DR
Practice Address - Street 2:SUITE 130
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3757
Practice Address - Country:US
Practice Address - Phone:425-806-5021
Practice Address - Fax:425-486-3949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 2084P0804X, 363A00000X, 363LP0808X, 364SP0808X, 390200000X
WAMD000342192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1112333Medicaid
WAG8866788Medicare PIN