Basic Information
Provider Information
NPI: 1033360144
EntityType: 2
ReplacementNPI:  
OrganizationName: PROVIDENCE HEALTH & SERVICES-WA
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Mailing Information
Address1: PO BOX 3369
Address2:  
City: PORTLAND
State: OR
PostalCode: 972083369
CountryCode: US
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Practice Location
Address1: 1321 COLBY AVE
Address2:  
City: EVERETT
State: WA
PostalCode: 982011665
CountryCode: US
TelephoneNumber: 4252613968
FaxNumber: 4252613967
Other Information
ProviderEnumerationDate: 10/07/2008
LastUpdateDate: 01/11/2018
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AuthorizedOfficialLastName: ANDERSON
AuthorizedOfficialFirstName: DONALD
AuthorizedOfficialMiddleName: WAYNE
AuthorizedOfficialTitleorPosition: ASSIST SECRETARY-ENROLLMENT
AuthorizedOfficialTelephone: 4255255392
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix: JR.
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LP0808X  N193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health
2084A0401X  Y193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine

No ID Information.


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