=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093864589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 03/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 N J ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 532-761-3898
-----------------------------------------------------
Fax | 532-830-6243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 N J ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98403-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 532-761-3898
-----------------------------------------------------
Fax | 532-830-6243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COMPLIANCE & POLICY ANALYST
-----------------------------------------------------
Name | STEPHANIE M. THELEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 253-761-3898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 76
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------