Healthcare Provider Details

I. General information

NPI: 1417118001
Provider Name (Legal Business Name): AFFILIATES IN MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 SE DOCK ST
OAK HARBOR WA
98277-4065
US

IV. Provider business mailing address

1091 SE DOCK ST
OAK HARBOR WA
98277-4065
US

V. Phone/Fax

Practice location:
  • Phone: 360-679-2779
  • Fax: 360-679-2777
Mailing address:
  • Phone: 360-679-2779
  • Fax: 360-679-2777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number601665352
License Number StateWA

VIII. Authorized Official

Name: MRS. TRACIE A MATTILA
Title or Position: OWNER
Credential:
Phone: 360-679-2779