Provider Demographics
NPI:1053498220
Name:CENTER FOR HUMAN SERVICES
Entity Type:Organization
Organization Name:CENTER FOR HUMAN SERVICES
Other - Org Name:CHS SHORELINE 170TH
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BERATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMILLION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-362-7282
Mailing Address - Street 1:17018 15TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5126
Mailing Address - Country:US
Mailing Address - Phone:206-362-7282
Mailing Address - Fax:206-362-7152
Practice Address - Street 1:17018 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-5126
Practice Address - Country:US
Practice Address - Phone:206-362-7282
Practice Address - Fax:206-362-7152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WA17015900251B00000X, 251S00000X, 261QR0405X
WA154261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1990308Medicaid