Basic Information
Provider Information | |||||||||
NPI: | 1467462952 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROVIDENCE HEALTH & SERVICES - WASHINGTON | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROVIDENCE ST PETER CHEMICAL DEPENDENCY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 909 N BROADWAY | ||||||||
Address2: | PBO/CREDENTIALING | ||||||||
City: | EVERETT | ||||||||
State: | WA | ||||||||
PostalCode: | 982011409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4253170246 | ||||||||
FaxNumber: | 4253170291 | ||||||||
Practice Location | |||||||||
Address1: | 4800 COLLEGE ST SE | ||||||||
Address2: |   | ||||||||
City: | LACEY | ||||||||
State: | WA | ||||||||
PostalCode: | 985034389 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604567575 | ||||||||
FaxNumber: | 3604935088 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 09/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NURMI | ||||||||
AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIR REVENUE CYCLE MGMT SWSA | ||||||||
AuthorizedOfficialTelephone: | 3604934081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X |   |   | Y |   | Hospital Units | Rehabilitation, Substance Use Disorder Unit |   |
ID Information
ID | Type | State | Issuer | Description | 3400017 | 05 | WA |   | MEDICAID | ST3729 | 01 | WA | REGENCE | OTHER | HO60IP | 05 | AL |   | MEDICAID |