Healthcare Provider Details

I. General information

NPI: 1689294563
Provider Name (Legal Business Name): NORTH SOUND BEHAVIORAL HEALTH ADMINISTRATIVE SERVICES ORGANIZATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 VALLEY MALL WAY STE 110
MOUNT VERNON WA
98273-5462
US

IV. Provider business mailing address

301 VALLEY MALL WAY STE 110
MOUNT VERNON WA
98273-5462
US

V. Phone/Fax

Practice location:
  • Phone: 360-416-7013
  • Fax:
Mailing address:
  • Phone: 360-416-7013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: CHARLES DEELENA
Title or Position: COMPLIANCE OFFICER/PROJECT MANAGER
Credential: MBA, MHA, CPHQ
Phone: 360-416-7013