Provider Demographics
NPI:1003199712
Name:DAYBREAK YOUTH SERVICES
Entity Type:Organization
Organization Name:DAYBREAK YOUTH SERVICES
Other - Org Name:DAYBREAK VANCOUVER OUTPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-444-7033
Mailing Address - Street 1:960 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-2241
Mailing Address - Country:US
Mailing Address - Phone:509-444-7033
Mailing Address - Fax:509-927-1851
Practice Address - Street 1:11818 SE MILL PLAIN BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-750-9635
Practice Address - Fax:360-334-9541
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAYBREAK YOUTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-20
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA06155400101YA0400X, 101YM0800X, 251B00000X, 101YM0800X
WA06 1554 00261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015313Medicaid
WA155400OtherWA STATE DBHR