Healthcare Provider Details

I. General information

NPI: 1609730480
Provider Name (Legal Business Name): SKYLAND RANCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43100 REITER RD
GOLD BAR WA
98251
US

IV. Provider business mailing address

43100 REITER RD
GOLD BAR WA
98251
US

V. Phone/Fax

Practice location:
  • Phone: 360-793-2611
  • Fax:
Mailing address:
  • Phone: 360-793-2611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE SPEAKS
Title or Position: BUSINESS ASSISTANT
Credential:
Phone: 425-772-0707