1417193749 NPI number — LAURA A HAMILTON CHEMICAL DEPENDENCY

Table of content: LAURA A HAMILTON CHEMICAL DEPENDENCY (NPI 1417193749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417193749 NPI number — LAURA A HAMILTON CHEMICAL DEPENDENCY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAMILTON
Provider First Name:
LAURA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHEMICAL DEPENDENCY
Provider Gender Code:
F

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:
1417193749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOKELAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98590-0500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-267-2508
Provider Business Mailing Address Fax Number:
360-267-6217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2373 OLD TOKELAND ROAD
Provider Second Line Business Practice Location Address:
BLDG E
Provider Business Practice Location Address City Name:
TOKELAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-267-8126
Provider Business Practice Location Address Fax Number:
360-267-6217
Provider Enumeration Date:
12/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  RC 00034789 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: CP 00004511 , 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: 1992817 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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