Healthcare Provider Details

I. General information

NPI: 1912515917
Provider Name (Legal Business Name): N W PEDIATRIC CENTER INC P S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 COOKS HILL RD
CENTRALIA WA
98531-9073
US

IV. Provider business mailing address

1911 COOKS HILL RD
CENTRALIA WA
98531-9073
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-6778
  • Fax: 360-736-6552
Mailing address:
  • Phone: 360-736-6778
  • Fax: 360-736-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA G MCKAY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 360-736-6778