Basic Information
| Provider Information | |||||||||
| NPI: | 1285895284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPPER SKAGIT INDIAN TRIBE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UPPER SKAGIT TRIBAL CD CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25944 COMMUNITY PLAZA WAY | ||||||||
| Address2: | |||||||||
| City: | SEDRO WOOLLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982849721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608547070 | ||||||||
| FaxNumber: | 3608547060 | ||||||||
| Practice Location | |||||||||
| Address1: | 25959 COMMUNITY PLAZA WAY | ||||||||
| Address2: | |||||||||
| City: | SEDRO WOOLLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982849721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608547070 | ||||||||
| FaxNumber: | 3608547060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH & SOCIAL SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 3608547065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UPPER SKAGIT INDIAN TRIBE | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP00001654 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1995281 | 05 | WA | MEDICAID | UP5781 | 01 | WA | REGENCE BLUE SHIELD | OTHER |