Healthcare Provider Details

I. General information

NPI: 1760519060
Provider Name (Legal Business Name): PENINSULA BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E 8TH ST
PORT ANGELES WA
98362-6129
US

IV. Provider business mailing address

118 E 8TH ST
PORT ANGELES WA
98362-6129
US

V. Phone/Fax

Practice location:
  • Phone: 360-457-0431
  • Fax: 360-457-0493
Mailing address:
  • Phone: 360-457-0431
  • Fax: 360-457-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. WENDY A SISK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 360-457-0431