Healthcare Provider Details

I. General information

NPI: 1710287479
Provider Name (Legal Business Name): WESTERN STATE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 STEILACOOM BLVD SW
TACOMA WA
98498-7212
US

IV. Provider business mailing address

9601 STEILACOOM BLVD SW
TACOMA WA
98498-7212
US

V. Phone/Fax

Practice location:
  • Phone: 253-756-3971
  • Fax:
Mailing address:
  • Phone: 253-756-3971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License NumberPY60040431
License Number StateWA

VIII. Authorized Official

Name: MS. LAUREL C. KELSO
Title or Position: PSYCHIATRIC SOCIALWORKER SUPERVISOR
Credential: LICSW
Phone: 253-756-2966