Organization
MAGNOLIA PSYCHIATRY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARC DAVID PELLICCIARO MD (PSYCHIATRIST)
(425) 467-1000
Entity
Organization
Contact information
Practice address
12729 NORTHUP WAY STE 6, BELLEVUE, WA 98005-1935
(425) 467-1000
(425) 467-0100
Mailing address
PO BOX 7239, BELLEVUE, WA 98008-1239
(425) 467-1000
(425) 467-0100
Taxonomy
Speciality
Code
Description
License number
State
2084P0802X
Addiction Psychiatry Physician
Primary
MD00036813
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MD00036813
WASHINGTON STATE MEDICAL LICENSE
WA
Enumeration date
06/15/2017
Last updated
04/17/2019
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