Provider Demographics
NPI:1447887427
Name:KITSAP PENINSULA OCD & ANXIETY SERVICES PLLC
Entity type:Organization
Organization Name:KITSAP PENINSULA OCD & ANXIETY SERVICES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:360-234-4623
Mailing Address - Street 1:2617 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-2043
Mailing Address - Country:US
Mailing Address - Phone:513-253-9402
Mailing Address - Fax:513-253-9402
Practice Address - Street 1:509 4TH ST STE 28
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337-1401
Practice Address - Country:US
Practice Address - Phone:360-234-6423
Practice Address - Fax:360-234-4624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-27
Last Update Date:2022-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0908067Medicaid