Etienne Clement Poufong, NP

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

License

AP61426687 Issued in WA

Practice address

1001 - Mountlake Terrace
Mountlake Terrace, WA 98043-7510

Phone

(469) 321-9543

NPI assigned

Jul 16, 2020

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in TX, WA, DC, CO4 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 4

Specialty

Nurse Practitioner

Education

Other, 2020

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Hawkins Psychiatry PCGroup PAC ID 5395893804, 6 clinicians

Mindful Therapy Group PCGroup PAC ID 4981872561, 654 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mindful Therapy Group PC

  • Clinical Social Worker
  • Mountlake Terrace, WA
  • NPI 1316238678

  Psychiatric/Mental Health

  Medicare reassignment Care Compare group NPD
• Hawkins Psychiatry PC

  • Psychiatry Physician
  • Arlington, TX
  • NPI 1003056607
  Medicare reassignment Care Compare group NPD
• Grow Healthcare Group PA

  • Mental Health Counselor
  • Miami, FL
  • NPI 1245845932

  CO, DC, Psychiatry, TX, WA

  Medicare reassignment NPD
• Integrative Psychiatry Services PLLC

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Seattle, WA
  • NPI 1669195202

  Mental Health (Including Community Mental Health Center)

  NPD Authorized official
• Hope Starts Here LLC

  • Psychiatry Physician
  • Arlington, TX
  • NPI 1053185983
  NPD (past)
• Mindful Behavioral LLC

  • Psychiatric/Mental Health Nurse Practitioner
  • Grand Prairie, TX
  • NPI 1811867872
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1594857600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1687651200000",
    "number": "1023626959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "708 CLEMENT DR",
            "city": "CEDAR HILL",
            "state": "TX",
            "postal_code": "751047352",
            "telephone_number": "469-321-9543",
            "fax_number": "817-471-3269"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1001 - MOUNTLAKE TERRACE",
            "city": "MOUNTLAKE TERRACE",
            "state": "WA",
            "postal_code": "980437510",
            "telephone_number": "469-321-9543"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2800 E Broad St Ste 400",
            "address_purpose": "LOCATION",
            "city": "Mansfield",
            "state": "TX",
            "postal_code": "760636414",
            "country_code": "US",
            "telephone_number": "469-321-9543",
            "fax_number": "682-227-2030",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "700 Milam St Ste 1300",
            "address_purpose": "LOCATION",
            "city": "Houston",
            "state": "TX",
            "postal_code": "770022736",
            "country_code": "US",
            "telephone_number": "469-321-9543",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "708 Clement dr",
            "address_purpose": "LOCATION",
            "city": "Cedar Hill",
            "state": "TX",
            "postal_code": "751047510",
            "country_code": "US",
            "telephone_number": "469-321-9543",
            "fax_number": "682-227-2030",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "POUFONG",
        "first_name": "ETIENNE",
        "middle_name": "CLEMENT",
        "name_prefix": "Mr.",
        "credential": "NP",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-07-16",
        "last_updated": "2023-06-25",
        "certification_date": "2023-06-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "TX",
            "license": "AP146155",
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "WA",
            "license": "AP61426687",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Shalea Ray Plasky
• Marsha Poischbeg
• Amy Melissa Porter, ARNP
• Devin Porter, DPT
• Lisa Marie Post, LPCC
• Samantha Rose Powers, PHD, MSW, LICSW
• Danielle Pranin
• Precision Proctology & Aesthetics
• Arynn Prescott, LMFTA
• Annika Previs

• Psychiatric/Mental Health Nurse Practitioner in Mountlake Terrace, WA
• Providers in Mountlake Terrace, WA by specialty
• Psychiatric/Mental Health Nurse Practitioner in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.