Basic Information
Provider Information | |||||||||
NPI: | 1851328447 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COWLITZ INDIAN TRIBE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | COWLITZ INDIAN TRIBAL HEALTH SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2429 | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986328486 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605758275 | ||||||||
FaxNumber: | 3605751950 | ||||||||
Practice Location | |||||||||
Address1: | 1044 11TH AVE | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 98632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605758275 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2006 | ||||||||
LastUpdateDate: | 04/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KELLER | ||||||||
AuthorizedOfficialFirstName: | SHAVON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 3603539431 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 2083P0901X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine | 261QH0100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.