Healthcare Provider Details

I. General information

NPI: 1124270715
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES- WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PACIFIC AVE STE 501
EVERETT WA
98201-4168
US

IV. Provider business mailing address

PO BOX 31001-4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-7550
  • Fax: 425-258-7450
Mailing address:
  • Phone: 425-358-9786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

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