Basic Information
| Provider Information | |||||||||
| NPI: | 1790831600 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SERENITY POINT COUNSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 W ROSE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993621762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095296036 | ||||||||
| FaxNumber: | 5095296038 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 W ROSE ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993621762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095296036 | ||||||||
| FaxNumber: | 5095296038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 10/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5095266036 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LICSW, CDP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 4486 SE | 01 | WA | REGENCE PROVIDER ID | OTHER | 1994417 | 05 | WA | MEDICAID |