Basic Information
| Provider Information | |||||||||
| NPI: | 1346266152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLUMBIA VALLEY COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CVCH CHELAN BEHAVIORAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 600 ORONDO AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096626000 | ||||||||
| FaxNumber: | 5096644590 | ||||||||
| Practice Location | |||||||||
| Address1: | 504 ORONDO AVE STE A | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096621269 | ||||||||
| FaxNumber: | 5096641037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/21/2012 | ||||||||
| NPIReactivationDate: | 07/25/2012 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5096643528 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBIA VALLEY COMMUNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 261QM0801X | 234 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0850X | 234 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | 234 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 2000949 | 05 | WA | MEDICAID |