Unknown Individual – Clinical Psychologist, NPI 1124175617

Unknown Individual is a healthcare provider. based in Olympia, Washington. specializing in Clinical Psychologist. They hold a License No. 35SI00410300 (NJ). The NPI Number for Unknown Individual is 1124175617

Main info

Organization
Inactive
26 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1124175617
Phone
(609) 417-7342
Address
1910 EVERGREEN PARK DR SW APT 702
Deactivation Date
31 August 2023

Doctor Profile

Medical School Name
OTHER
Secondary Phone
6094177342
Graduation Year
2000 (26 years ago)
PAC ID
9032219324
Professional Enrollment ID
I20200713000363
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience19
Completeness75
Years active:0State licenses:1Digital endpointsOther names

Provider Addresses for Unknown Individual

  • 1910 EVERGREEN PARK DR SW APT 702

    OLYMPIA, WA 985025913

    Phone: (609) 417-7342

    Type: Mailing

  • 704 E Main St

    Suite A

    Moorestown, NJ 080573070

    Phone: (856) 722-1338

    Fax: (856) 608-7630

    Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

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Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

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Medicare Utilization (FFS)

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No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 98502)

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Reviews

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Frequently asked questions

Is there an official ID for Unknown Individual in U.S. healthcare records?
The official identifier for Unknown Individual is NPI 1124175617.
Who updates status for Unknown Individual?
NPPES shows Unknown Individual as inactive; dates on the record explain the timeline when available.
How would a patient describe Unknown Individual's focus?
For Unknown Individual, the primary taxonomy reads as Clinical Psychologist. Clinical services aligned with this taxonomy classification.
Is Unknown Individual located near Olympia?
Unknown Individual currently maps to Olympia, Washington in this extract.
What does 3 location(s) imply?
3 practice locations appear in the available data.

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