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General NPI Number Information
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NPI Number | 1104024348
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Entity Type | Organization
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Legal Business Name | PROVIDENCE HEALTH & SERVICE WASHINGTON
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Dates
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Enumeration Date | 07/10/2007
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Last Update Date | 12/22/2010
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Provider Practice Location Address
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Address Line | 218-A MAIN STREET
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City | MORTON
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State | WA
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Zip | 98356-0000
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Country | US
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Telephone | 360-496-6216
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Fax | 360-496-6232
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Provider Business Mailing Address
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Address Line | PO BOX 34439
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City | SEATTLE
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State | WA
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Zip | 98124-1439
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Country | US
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Telephone | 425-525-6778
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Fax | 425-525-6700
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Authorized Official
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Title or Position | PAYOR CREDENTIALING MANAGER
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Name | NICOLE QUINN
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Credential |
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Telephone | 425-525-6715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
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License Number |
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License Number State |
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