1568137370 NPI number — PILGRIM BEHAVIORAL 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 1568137370 NPI number — PILGRIM BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PILGRIM BEHAVIORAL 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:
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:
1568137370
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
46 VILLAGE WAY # 107
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT LUDLOW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98365-5102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-501-8293
Provider Business Mailing Address Fax Number:
505-521-5149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4405 7TH AVENUE STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-501-8293
Provider Business Practice Location Address Fax Number:
505-521-5149
Provider Enumeration Date:
08/13/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PILGRIM
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, CLINICAL DIRECTOR
Authorized Official Telephone Number:
505-501-8293

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 44002335 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1568137370 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007433 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".




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