Healthcare Provider Details

I. General information

NPI: 1588747059
Provider Name (Legal Business Name): NORTHWEST INDIAN TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 E. YOUNG STREET BOX 477
ELMA WA
98541
US

IV. Provider business mailing address

308 EAST YOUNG STREET BOX 477
ELMA WA
98541-0000
US

V. Phone/Fax

Practice location:
  • Phone: 360-482-2674
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberRTF1034
License Number StateWA

VIII. Authorized Official

Name: MS. JUNE O'BRIEN
Title or Position: DIRECTOR
Credential:
Phone: 360-470-1474