1811104763 NPI number — THE CAMELOT SOCIETY

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 1811104763 NPI number — THE CAMELOT SOCIETY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CAMELOT SOCIETY
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:
1811104763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18606 BOTHELL WAY NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOTHELL
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98011-1929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-481-5853
Provider Business Mailing Address Fax Number:
425-481-5763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5027 NE 188TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-481-5853
Provider Business Practice Location Address Fax Number:
425-481-5763
Provider Enumeration Date:
05/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CALKINS
Authorized Official First Name:
AUTUMN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
425-481-5853

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4963203 . This is a "ICFMR GROUP HOME" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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