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General NPI Number Information
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NPI Number | 1265748388
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Entity Type | Organization
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Legal Business Name | GREATER LAKES MENTAL HEALTH
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Dates
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Enumeration Date | 08/26/2010
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Last Update Date | 08/26/2010
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Provider Practice Location Address
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Address Line | 9330 59TH AVE SW
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City | LAKEWOOD
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State | WA
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Zip | 98499-2858
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Country | US
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Telephone | 253-620-5014
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Fax | 253-620-5831
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Provider Business Mailing Address
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Address Line | 9330 59TH AVE SW
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City | LAKEWOOD
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State | WA
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Zip | 98499-2858
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Country | US
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Telephone | 253-620-5014
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Fax | 253-620-5831
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Authorized Official
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Title or Position | STAFF
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Name | MS. RENEE JOHNSON
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Credential | RESOURCES
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Telephone | 253-620-5014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | CG 60158344
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License Number State | WA
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