Provider Demographics
NPI:1043636442
Name:CHEHALIS TSAPOWUM MENTAL HEALTH
Entity Type:Organization
Organization Name:CHEHALIS TSAPOWUM MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-867-0709
Mailing Address - Street 1:420 HOWANUT RD
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98568-9659
Mailing Address - Country:US
Mailing Address - Phone:360-709-1628
Mailing Address - Fax:360-273-8957
Practice Address - Street 1:420 HOWANUT RD
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:WA
Practice Address - Zip Code:98568-9659
Practice Address - Country:US
Practice Address - Phone:360-709-1628
Practice Address - Fax:360-273-8957
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHEHALIS TSAPOWUM BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-03-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA14 0096 00261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1346383379OtherCHEHALIS MEDICAL NPI
WA1008323OtherMEDICAID PROVIDER ONE DOMAIN ID