Healthcare Provider Details

I. General information

NPI: 1538412630
Provider Name (Legal Business Name): COWLITZ INDIAN TRIBE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2012
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 NE 40TH ST
VANCOUVER WA
98661-3058
US

IV. Provider business mailing address

PO BOX 2429
LONGVIEW WA
98632-8486
US

V. Phone/Fax

Practice location:
  • Phone: 360-353-9431
  • Fax: 360-353-9440
Mailing address:
  • Phone: 206-721-5170
  • Fax: 206-721-6288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAVON KELLER
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 360-353-9431