Basic Information
Provider Information | |||||||||
NPI: | 1043281736 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKE WHATCOM RESIDENTIAL & TREATMENT CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3600 MERIDIAN ST | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982251756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606766000 | ||||||||
FaxNumber: | 3606766006 | ||||||||
Practice Location | |||||||||
Address1: | 3600 MERIDIAN ST | ||||||||
Address2: |   | ||||||||
City: | BELLINGHAM | ||||||||
State: | WA | ||||||||
PostalCode: | 982251756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606766000 | ||||||||
FaxNumber: | 3606766006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 09/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ZAPIEN | ||||||||
AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | FINANCE/IT DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3606766000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QR0405X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 363LP2300X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 251S00000X | 028 | WA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 7043615 | 05 | WA |   | MEDICAID |