Healthcare Provider Details

I. General information

NPI: 1639601719
Provider Name (Legal Business Name): ESD 113 SOUND TO HARBOR HEAD START/ECEAP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 TYEE DR SW
TUMWATER WA
98512-7356
US

IV. Provider business mailing address

6005 TYEE DR SW
TUMWATER WA
98512-7356
US

V. Phone/Fax

Practice location:
  • Phone: 360-464-6800
  • Fax: 360-464-6903
Mailing address:
  • Phone: 360-464-6800
  • Fax: 360-464-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW SOLOMON
Title or Position: ASSISTANT SUPERINTENDENT
Credential:
Phone: 360-464-6800