Basic Information
| Provider Information | |||||||||
| NPI: | 1730565045 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHUGACHMIUT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1840 BRAGAW STREET | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075624155 | ||||||||
| FaxNumber: | 9072780300 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 BRAGAW ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995083463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075624155 | ||||||||
| FaxNumber: | 9075632891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 12/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | BAKER | ||||||||
| AuthorizedOfficialFirstName: | KELLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEALTH SERVICES DIVISION DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9075624155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101Y00000X | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | AK | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1632379 | 05 | AK | MEDICAID |