=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780913657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELECARE MENTAL HEALTH SERVICES OF WASHINGTON, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2009
-----------------------------------------------------
Last Update Date | 01/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9601 STEILACOOM BLVD SW BLDG 27
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98498-7212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-589-5334
-----------------------------------------------------
Fax | 253-584-1508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1080 MARINA VILLAGE PKWY SUITE 100
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-6427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-337-7950
-----------------------------------------------------
Fax | 510-337-7969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO, VP
-----------------------------------------------------
Name | MARSHALL LANGFELD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-337-7950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number | RTF.FS.60118424
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------