Healthcare Provider Details

I. General information

NPI: 1487659579
Provider Name (Legal Business Name): COLUMBIA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 14TH AVENUE
LONGVIEW WA
98632-2316
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-0203
  • Fax: 360-423-5086
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-423-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH ANDREW MCDANIEL
Title or Position: CEO
Credential:
Phone: 360-423-0203