=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902540362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELECARE MENTAL HEALTH SERVICES OF WASHINGTON INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2022
-----------------------------------------------------
Last Update Date | 02/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 ANDOVER PARK W STE 107
-----------------------------------------------------
City | TUKWILA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98188-3911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-372-2028
-----------------------------------------------------
Fax | 360-200-7705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1080 MARINA VILLAGE PKWY STE 100
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-1078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-337-7950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER RELATIONS SUPERVISOR
-----------------------------------------------------
Name | LORENA LOPEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-747-0552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------