Basic Information
Provider Information | |||||||||
NPI: | 1003939034 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIONEER HUMAN SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PIONEER COUNSELING TACOMA - FAWCETT CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7440 W. MARGINAL WAY S. | ||||||||
Address2: | PIONEER HUMAN SERVICES - CONTRACTS | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981084141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067681990 | ||||||||
FaxNumber: | 2067688910 | ||||||||
Practice Location | |||||||||
Address1: | 1111 FAWCETT AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984022024 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2532740484 | ||||||||
FaxNumber: | 2532741457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2007 | ||||||||
LastUpdateDate: | 01/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOOLWORTH | ||||||||
AuthorizedOfficialFirstName: | STEVE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, TREATMENT & REENTRY | ||||||||
AuthorizedOfficialTelephone: | 2067667018 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 27114000 | WA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1995091 | 05 | WA |   | MEDICAID |