Provider Demographics
NPI:1902779796
Name:DOMAIN PSYCHIATRY, PLLC
Entity type:Organization
Organization Name:DOMAIN PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-208-8957
Mailing Address - Street 1:PO BOX 257
Mailing Address - Street 2:PMB 11130
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0257
Mailing Address - Country:US
Mailing Address - Phone:206-208-8957
Mailing Address - Fax:
Practice Address - Street 1:819 N 49TH ST STE 302
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6577
Practice Address - Country:US
Practice Address - Phone:206-208-8957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty