Healthcare Provider Details

I. General information

NPI: 1003964545
Provider Name (Legal Business Name): CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 23RD AVE S
SEATTLE WA
98144
US

IV. Provider business mailing address

100 23RD AVE S
SEATTLE WA
98144-2302
US

V. Phone/Fax

Practice location:
  • Phone: 206-323-6336
  • Fax: 206-328-5699
Mailing address:
  • Phone: 206-323-6336
  • Fax: 206-328-5699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number081
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number081
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number081
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number081
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number17034300
License Number StateWA

VIII. Authorized Official

Name: STEPHANIE M. THELEN
Title or Position: COMPLIANCE & POLICY ANALYST
Credential:
Phone: 253-761-3898