Basic Information
Provider Information | |||||||||
NPI: | 1467855353 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HOUSE ON BROADWAY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 403 | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986327260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602005419 | ||||||||
FaxNumber: | 3602006736 | ||||||||
Practice Location | |||||||||
Address1: | 748 14TH AVE | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986322315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602005419 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2014 | ||||||||
LastUpdateDate: | 10/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARSON | ||||||||
AuthorizedOfficialFirstName: | CAMERON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
AuthorizedOfficialTelephone: | 3602005419 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 313 | WA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.