Healthcare Provider Details

I. General information

NPI: 1790008928
Provider Name (Legal Business Name): EDUCATIONAL SERVICE DISTRICT 112
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE 65 AVENUE
VANCOUVER WA
98661-6812
US

IV. Provider business mailing address

2500 NE 65 AVENUE
VANCOUVER WA
98661-6812
US

V. Phone/Fax

Practice location:
  • Phone: 360-750-7500
  • Fax: 360-906-1010
Mailing address:
  • Phone: 360-750-7500
  • Fax: 360-906-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. GAVIN HOTTMAN
Title or Position: BUDGET ANALYST
Credential:
Phone: 360-750-7500