NPIMap

Organization Active NPI

Puget Sound Psychiatric Center, PS

Doing business as PSPC

  • Psychiatry Physician
  • Bothell, WA
National Provider Identifier
1114254729
Registry record updated Jan 23, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
License
MD00034219 Issued in WA
Legal business name
PUGET SOUND PSYCHIATRIC CENTER, PS
Doing business as
PSPC
Practice address
10634 E Riverside Dr
Suite 130
Bothell, WA 98011-3757
Phone
(425) 806-5021
Fax
(425) 486-3949
NPI assigned
Nov 3, 2009
Last updated
Jan 23, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 23, 2012

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

Authorized official

Name
Dr. Syed Jamal Mustafa, MDNPI 1609883180
Title
Medical Director
Phone
(425) 806-5021

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 11

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X NU
Psychiatric/Mental Health Nurse Practitioner 363LP0808X NU
Psychiatric/Mental Health Clinical Nurse Specialist 364SP0808X NU
Mental Health Counselor 101YM0800X NU
Clinical Psychologist 103TC0700X NU
Clinical Social Worker 1041C0700X NU
Marriage & Family Therapist 106H00000X NU
Student in an Organized Health Care Education/Training Program 390200000X NU
Psychiatry Physician 2084P0800X NU
Psychiatry Physician 2084P0800X MD00034219 WA Primary
Child & Adolescent Psychiatry Physician 2084P0804X NU

Addresses

Primary practice location

10634 E Riverside Dr
Suite 130
Bothell, WA 98011-3757

Mailing address

10634 E Riverside Dr
Suite 130
Bothell, WA 98011-3758
Phone (425) 806-5021

Other identifiers 1

IdentifierTypeStateIssuer
1112333MedicaidWA

Other names 1

  • PSPC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070816000399 WA Part B Supplier - Clinic/Group Practice 4688766066 Receives reassigned benefits from 9 practitioners
Practice locations: Bothell, WA

National Provider Directory

National Provider Directory

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 9

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1257206400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1327276800000",
    "number": "1114254729",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10634 E RIVERSIDE DR",
            "address_2": "SUITE 130",
            "city": "BOTHELL",
            "state": "WA",
            "postal_code": "980113758",
            "telephone_number": "425-806-5021",
            "fax_number": "425-486-3949"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10634 E RIVERSIDE DR",
            "address_2": "SUITE 130",
            "city": "BOTHELL",
            "state": "WA",
            "postal_code": "980113757",
            "telephone_number": "425-806-5021",
            "fax_number": "425-486-3949"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PUGET SOUND PSYCHIATRIC CENTER, PS",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-11-03",
        "last_updated": "2012-01-23",
        "status": "A",
        "authorized_official_last_name": "MUSTAFA",
        "authorized_official_first_name": "SYED",
        "authorized_official_middle_name": "JAMAL",
        "authorized_official_title_or_position": "MEDICAL DIRECTOR",
        "authorized_official_telephone_number": "425-806-5021",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "364SP0808X",
            "taxonomy_group": "",
            "desc": "Clinical Nurse Specialist, Psychiatric/Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "",
            "desc": "Marriage & Family Therapist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "WA",
            "license": "MD00034219",
            "primary": true
        },
        {
            "code": "2084P0804X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Child & Adolescent Psychiatry",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1112333",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PSPC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bothell, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 23, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.