Provider Demographics
NPI:1154987931
Name:ADVANCED WELLNESS MENTAL HEALTH, PLLC
Entity type:Organization
Organization Name:ADVANCED WELLNESS MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:KRISTI
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:206-414-9060
Mailing Address - Street 1:26828 MAPLE VALLEY HIGHWAY
Mailing Address - Street 2:#202
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-1262
Mailing Address - Country:US
Mailing Address - Phone:206-414-9060
Mailing Address - Fax:888-977-3120
Practice Address - Street 1:26828 MAPLE VALLEY HIGHWAY
Practice Address - Street 2:#202
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-1262
Practice Address - Country:US
Practice Address - Phone:206-414-9060
Practice Address - Fax:888-977-3120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-16
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty