Provider Demographics
NPI:1003008046
Name:BLUE MOUNTAIN HEART TO HEART
Entity Type:Organization
Organization Name:BLUE MOUNTAIN HEART TO HEART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:509-529-4744
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2330 EASTGATE ST STE 105
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1559
Practice Address - Country:US
Practice Address - Phone:509-529-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7405905Medicaid