Basic Information
| Provider Information | |||||||||
| NPI: | 1336129295 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UPPER SKAGIT INDIAN TRIBE | ||||||||
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| OtherOrganizationName: | UPPER SKAGIT TRIBAL 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: | 01/18/2006 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | MARILYN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | TRIBAL VICE-CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 3608547039 | ||||||||
| 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 | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TC1900X | ;H00008445 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 104100000X | RC00047287 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 133V00000X | DI00001414 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | LP00022558 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 208600000X | MD00012663 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208D00000X | MD00012663 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363LF0000X | AP30006120 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 261QF0400X | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1981323 | 05 | WA | MEDICAID | 8024291 | 05 | WA | MEDICAID | 9645573 | 05 | WA | MEDICAID | 7084338 | 05 | WA | MEDICAID | 1008805 | 05 | WA | MEDICAID | 8466286 | 05 | WA | MEDICAID | 1995281 | 05 | WA | MEDICAID | 7203805 | 05 | WA | MEDICAID |