Basic Information
Provider Information | |||||||||
NPI: | 1235689381 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SWINOMISH INDIAN TRIBAL COMMUNITY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SWINOMISH WELLNESS PROGRAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17337 RESERVATION RD | ||||||||
Address2: |   | ||||||||
City: | LA CONNER | ||||||||
State: | WA | ||||||||
PostalCode: | 982578802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604661024 | ||||||||
FaxNumber: | 3604667634 | ||||||||
Practice Location | |||||||||
Address1: | 17337 RESERVATION RD | ||||||||
Address2: |   | ||||||||
City: | LA CONNER | ||||||||
State: | WA | ||||||||
PostalCode: | 982578802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604661024 | ||||||||
FaxNumber: | 3604667634 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/12/2016 | ||||||||
LastUpdateDate: | 10/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTIN | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLER | ||||||||
AuthorizedOfficialTelephone: | 3605882735 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60166467 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | CP60166467 | 01 | WA | WASHINGTON STATE | OTHER |