Healthcare Provider Details

I. General information

NPI: 1346547064
Provider Name (Legal Business Name): AL'TA COUNSELING & TESTING L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 BROADWAY SUITE 102
TACOMA WA
98402-3735
US

IV. Provider business mailing address

702 BROADWAY SUITE 102
TACOMA WA
98402-3735
US

V. Phone/Fax

Practice location:
  • Phone: 253-473-7586
  • Fax: 253-590-0211
Mailing address:
  • Phone: 253-473-7586
  • Fax: 253-590-0211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number27145100
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number27145100
License Number StateWA

VIII. Authorized Official

Name: MR. JEREMY MATHESON WEKELL
Title or Position: ADMINISTRATOR
Credential: CDP, SAP
Phone: 253-473-7586