1447638853 NPI number — ISLAND BEHAVIORAL MEDICINE, PS

Table of content: (NPI 1447638853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447638853 NPI number — ISLAND BEHAVIORAL MEDICINE, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND BEHAVIORAL MEDICINE, PS
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:
6
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:
1447638853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 378
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANACORTES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98221-0378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-682-5016
Provider Business Mailing Address Fax Number:
360-682-5476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3208 K AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANACORTES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-682-5016
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CASEY
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
LOUISE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-682-5016

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH60428818 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PY60620631 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LW60395422 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: OP60248624 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: LF60125307 , 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: 2044886 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: G8957249 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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