Healthcare Provider Details

I. General information

NPI: 1114195898
Provider Name (Legal Business Name): THE EVERGREEN STATE COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 02/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 EVERGREEN PKWY NW SEMINAR 1 2110
OLYMPIA WA
98505-0005
US

IV. Provider business mailing address

2700 EVERGREEN PKWY NW SEMINAR 1 2110
OLYMPIA WA
98505-0005
US

V. Phone/Fax

Practice location:
  • Phone: 360-867-6808
  • Fax: 360-867-6787
Mailing address:
  • Phone: 360-867-6808
  • Fax: 360-867-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH MCHUGH
Title or Position: DIRECTOR OF COUNSELING & HEALTH SVC
Credential: PA-C
Phone: 360-867-6808