Basic Information
| Provider Information | |||||||||
| NPI: | 1376056796 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOME SOCIETY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 WALLA WALLA AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988011523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096630034 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1014 WALLA WALLA AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988011523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096630034 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2017 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | ANA | ||||||||
| AuthorizedOfficialMiddleName: | LILIA | ||||||||
| AuthorizedOfficialTitleorPosition: | WISE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 5096630034 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | CG60549819 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CG60549819 | 01 | WA | COUNSELOR AGENCY AFFILIATED REGISTRATION | OTHER |