Healthcare Provider Details

I. General information

NPI: 1225596232
Provider Name (Legal Business Name): QUILEUTE COUNSELING AND RECOVERY MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 QUILEUTE HEIGHTS LOOP
LA PUSH WA
98350
US

IV. Provider business mailing address

PO BOX 189
LA PUSH WA
98350-0189
US

V. Phone/Fax

Practice location:
  • Phone: 360-374-3358
  • Fax:
Mailing address:
  • Phone: 360-374-3358
  • Fax: 360-374-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: GARY BRYAN GOODWIN
Title or Position: BILLING AGENCY
Credential:
Phone: 360-867-0709