Provider Demographics
NPI:1043993801
Name:ALASKA ADVANCED BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:ALASKA ADVANCED BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:231-388-5344
Mailing Address - Street 1:PO BOX 262
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0262
Mailing Address - Country:US
Mailing Address - Phone:231-388-5344
Mailing Address - Fax:
Practice Address - Street 1:203 WEST E ST
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:231-388-5344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)