Provider Demographics
NPI:1215334982
Name:PUGET MENTAL CARE LLC
Entity type:Organization
Organization Name:PUGET MENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPEC
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:253-304-8039
Mailing Address - Street 1:4009 BRIDGEPORT WAY W # 1A
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4009 BRIDGEPORT WAY W # 1A
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4326
Practice Address - Country:US
Practice Address - Phone:253-503-6761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60411730261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)