Basic Information
| Provider Information | |||||||||
| NPI: | 1114336237 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HUMAN SERVICES OF WA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ACES COMMUNITY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 E SCHNEIDMILLER AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838547085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086190190 | ||||||||
| FaxNumber: | 2086190195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 E SCHNEIDMILLER AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838547085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086190190 | ||||||||
| FaxNumber: | 2086190195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2014 | ||||||||
| LastUpdateDate: | 08/04/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUPREE | ||||||||
| AuthorizedOfficialFirstName: | AMIKA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2086190190 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE PROVIDENCE SERVICE CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.