Basic Information
| Provider Information | |||||||||
| NPI: | 1093939548 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOONAH BHVRL HLTH PROGRAM | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | HOONAH MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 103 | ||||||||
| Address2: | |||||||||
| City: | HOONAH | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998290103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079453235 | ||||||||
| FaxNumber: | 9079453239 | ||||||||
| Practice Location | |||||||||
| Address1: | 568 RAVIN DRIVE | ||||||||
| Address2: | |||||||||
| City: | HOONAH | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998290103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9079453235 | ||||||||
| FaxNumber: | 9079453239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LEAD CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9079453235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | AK | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | AK | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | AK | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MH9829 | 05 | AK | MEDICAID | DA0129 | 05 | AK | MEDICAID |