Basic Information
| Provider Information | |||||||||
| NPI: | 1396179545 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BASICS NORTHWEST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8282 28TH CT NE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985167162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609156868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8282 28TH CT NE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985167162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609156868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2013 | ||||||||
| LastUpdateDate: | 08/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | WOODARD | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3609156868 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MED BCBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 103K00000X | 05 | WA | MEDICAID |