1114386711 NPI number — COUNSELING SERVICES OF WALLA WALLA

Table of content: (NPI 1114386711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114386711 NPI number — COUNSELING SERVICES OF WALLA WALLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNSELING SERVICES OF WALLA WALLA
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:
1114386711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3324
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-0367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-876-0100
Provider Business Mailing Address Fax Number:
509-876-0101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
127 E ROSE ST
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-876-0100
Provider Business Practice Location Address Fax Number:
509-876-0101
Provider Enumeration Date:
02/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRADLEY
Authorized Official First Name:
MARTI
Authorized Official Middle Name:
K
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-876-0100

Provider Taxonomy Codes

  • Taxonomy code: 305S00000X , with the licence number:  LW00006668 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1041C0700X . This is a "TAXONOMY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: LW00006668 . This is a "LICSW LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 603-575-701 . This is a "UBI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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