1225596232 NPI number — QUILEUTE COUNSELING AND RECOVERY MENTAL HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225596232 NPI number — QUILEUTE COUNSELING AND RECOVERY MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUILEUTE COUNSELING AND RECOVERY MENTAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225596232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 189
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PUSH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98350-0189
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-374-3358
Provider Business Mailing Address Fax Number:
360-374-2644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 QUILEUTE HEIGHTS LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PUSH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-374-3358
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GOODWIN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
BRYAN
Authorized Official Title or Position:
BILLING AGENCY
Authorized Official Telephone Number:
360-867-0709

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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