Healthcare Provider Details

I. General information

NPI: 1174570949
Provider Name (Legal Business Name): WILLAPA COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 PACIFIC AVE N
LONG BEACH WA
98631-3300
US

IV. Provider business mailing address

2204 PACIFIC AVE N
LONG BEACH WA
98631-3300
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3787
  • Fax: 360-642-2096
Mailing address:
  • Phone: 360-642-3787
  • Fax: 360-642-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberJ600618510
License Number StateWA

VIII. Authorized Official

Name: LINDSEY MATZEN
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 360-642-3783