Provider Demographics
NPI:1275369563
Name:EBTSL PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:EBTSL PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:425-361-9272
Mailing Address - Street 1:2225 E MURRAY HOLLADAY RD STE 116
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5382
Mailing Address - Country:US
Mailing Address - Phone:877-919-4521
Mailing Address - Fax:
Practice Address - Street 1:2225 E MURRAY HOLLADAY RD STE 116
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5382
Practice Address - Country:US
Practice Address - Phone:877-919-4521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVIDENCE BASED TREATMENT CENTERS OF SEATTLE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty