Healthcare Provider Details

I. General information

NPI: 1528264561
Provider Name (Legal Business Name): SKOKOMISH INDIAN NATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N 561 TRIBAL CENTER RD
SHELTON WA
98584
US

IV. Provider business mailing address

N 561 TRIBAL CENTER RD
SHELTON WA
98584
US

V. Phone/Fax

Practice location:
  • Phone: 360-426-7788
  • Fax: 360-462-0082
Mailing address:
  • Phone: 360-426-7788
  • Fax: 360-462-0082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00000655
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00002317
License Number StateWA

VIII. Authorized Official

Name: MALYNN FOSTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 360-426-7788