Healthcare Provider Details

I. General information

NPI: 1548384126
Provider Name (Legal Business Name): TSAPOWUM-CHEHALIS TRIBAL CHEMICAL DEPENDANCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 HOWANUT RD
OAKVILLE WA
98568
US

IV. Provider business mailing address

PO BOX 570
OAKVILLE WA
98568-0570
US

V. Phone/Fax

Practice location:
  • Phone: 360-858-1660
  • Fax: 360-273-2723
Mailing address:
  • Phone: 360-858-1660
  • Fax: 360-273-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number14 0096 00
License Number StateWA

VIII. Authorized Official

Name: MARSHA KAY POCKAT
Title or Position: BILLING COORDINATOR
Credential:
Phone: 360-858-1660