Basic Information
| Provider Information | |||||||||
| NPI: | 1396496972 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENECA FAMILY OF AGENCIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13925 INTERURBAN AVE S STE 120 | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981685718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069480096 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23801 16TH AVE S | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981985266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069480096 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2022 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOBSON | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | QUALITY ASSURANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5107255727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SENECA FAMILY OF AGENCIES | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 200242 | 05 | WA | MEDICAID |