Basic Information
| Provider Information | |||||||||
| NPI: | 1366634552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONFEDERATED TRIBES AND BANDS OF THE YAKAMA NATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 FORT ROAD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655121 | ||||||||
| FaxNumber: | 5098742113 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SIGNAL PEAK ROAD | ||||||||
| Address2: | |||||||||
| City: | WHITE SWAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098742979 | ||||||||
| FaxNumber: | 5098742113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | SWAN | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5098742979 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TP0016X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Prescribing (Medical) | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1981265 | 05 | WA | MEDICAID |