Basic Information
| Provider Information | |||||||||
| NPI: | 1598044174 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAUNEKA | ||||||||
| FirstName: | PRISCILLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | EMT 1 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORRIS | ||||||||
| OtherFirstName: | PRISCILLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 528 | ||||||||
| Address2: | ATTN: BH SOBERING CENTER | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075436830 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1360 CALISTA DR. | ||||||||
| Address2: | BH SOBERING CENTER | ||||||||
| City: | BETHEL | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995590528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075456830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2011 | ||||||||
| LastUpdateDate: | 06/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 146M00000X | 13289003 | AK | N | Emergency Medical Service Providers | Emergency Medical Technician, Intermediate |
ID Information
| ID | Type | State | Issuer | Description | 1020986 | 05 | AK | MEDICAID |