1689302606 NPI number — CANYON LAKES FAMILY COUNSELING

Table of content: (NPI 1689302606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689302606 NPI number — CANYON LAKES FAMILY COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYON LAKES FAMILY COUNSELING
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:
1689302606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 E TWIGGS ST
Provider Second Line Business Mailing Address:
STE 1000 PMB 91825
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33602-3931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 W 34TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99337-8211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-795-1944
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2022

Additional Information

Authorized Official

Authorized Official Last Name:
OWENS
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-795-1944

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)

  • Identifier: 2039983 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com