Basic Information
| Provider Information | |||||||||
| NPI: | 1245438738 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE HEALTH & SERVICE WASHINGTON | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROVIDENCE ADDICTIONS RECOVERY CTR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255256778 | ||||||||
| FaxNumber: | 4255256700 | ||||||||
| Practice Location | |||||||||
| Address1: | 1322 COMMERCE AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604148771 | ||||||||
| FaxNumber: | 3604148776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2007 | ||||||||
| LastUpdateDate: | 12/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | QUINN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PAYOR CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4255256715 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 08 0983 00 | 05 | WA | MEDICAID | 631762 | 01 | WA | LONGVIEW BUSINESS LICENSE | OTHER | 602 399 531 | 01 | WA | UBI MASTER LICENSE | OTHER |