Basic Information
| Provider Information | |||||||||
| NPI: | 1083771851 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONSEJO COUNSELING AND REFERRAL SERVICE - SOUTH PARK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3808 S ANGELINE ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981181712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064614880 | ||||||||
| FaxNumber: | 2064616989 | ||||||||
| Practice Location | |||||||||
| Address1: | 8615 14TH AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981084806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064614880 | ||||||||
| FaxNumber: | 2067620489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAREDES | ||||||||
| AuthorizedOfficialFirstName: | MARIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2064614880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 600287044 | WA | N | Agencies | Community/Behavioral Health | 251S00000X | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1994755 | 05 | WA | MEDICAID | 1995208 | 05 | WA | MEDICAID | 135400 | 01 | WA | DBHR SITE LICENSE ID | OTHER | 1992502 | 05 | WA | MEDICAID |