Basic Information
| Provider Information | |||||||||
| NPI: | 1184101966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONSEJO COUNSELING AND REFERRAL SERVICE - SHELTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3808 S ANGELINE ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981181712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064614880 | ||||||||
| FaxNumber: | 2064616989 | ||||||||
| Practice Location | |||||||||
| Address1: | 627 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985843504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607635610 | ||||||||
| FaxNumber: | 3604620449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2018 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOSCHMA | ||||||||
| AuthorizedOfficialFirstName: | SHANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | IS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2064614880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | WA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 200488 | 01 | WA | DBHR SITE LICENSE ID | OTHER |