Healthcare Provider Details

I. General information

NPI: 1023226685
Provider Name (Legal Business Name): SQUAXIN ISLAND TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 SE KLAH CHE MIN DRIVE
SHELTON WA
98584
US

IV. Provider business mailing address

90 SE KLAH CHE MIN DRIVE
SHELTON WA
98584
US

V. Phone/Fax

Practice location:
  • Phone: 360-427-9006
  • Fax: 360-427-1951
Mailing address:
  • Phone: 360-427-9006
  • Fax: 360-427-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number600371470
License Number StateWA

VIII. Authorized Official

Name: EDWARD J FOX
Title or Position: HHS DIRECTOR
Credential: PHD
Phone: 360-427-9006