Healthcare Provider Details

I. General information

NPI: 1427530302
Provider Name (Legal Business Name): PLYMOUTH HOUSING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 3RD AVE
SEATTLE WA
98121-2321
US

IV. Provider business mailing address

2113 3RD AVE
SEATTLE WA
98121-2321
US

V. Phone/Fax

Practice location:
  • Phone: 206-374-9409
  • Fax:
Mailing address:
  • Phone: 206-374-9409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: KELLI LARSEN
Title or Position: CHIEF PROGRAM OFFICER
Credential:
Phone: 206-374-9409