MEDICARE: COLUMBIA BASIN FAMILY THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1962271239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBIA BASIN FAMILY THERAPY, LLC

Provider Business Mailing Address
First Line	:	100 WALLA WALLA AVE
Second Line	:
City	:	ELTOPIA
State	:	WA
Zip	:	99330-9611
Country	:	US
Telephone Number	:	509-845-6270
Fax Number	:

Provider Business Practice Location Address
First Line	:	1619 W OCTAVE ST
Second Line	:
City	:	PASCO
State	:	WA
Zip	:	99301-4045
Country	:	US
Telephone Number	:	509-845-6270
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICAL SUPERVISOR
Name	:	JESSICA INFANTE-CASTRO
Credential	:	MA
Telephone Number	:	509-845-6270

Provider Enumeration Date	:	12/27/2023
Last Update Date	:	12/27/2023

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