Healthcare Provider Details

I. General information

NPI: 1477563344
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 E REZANOF DR
KODIAK AK
99615-6505
US

IV. Provider business mailing address

PO BOX 31001-4162
PASADENA CA
91110-4162
US

V. Phone/Fax

Practice location:
  • Phone: 907-481-2400
  • Fax: 907-481-2419
Mailing address:
  • Phone: 907-486-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number297340
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number297340
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number297340
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number297340
License Number StateAK
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number297340
License Number StateAK

VIII. Authorized Official

Name: MR. DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786