Provider Demographics
NPI:1063502946
Name:TULALIP TRIBES OF WASHINGTON
Entity Type:Organization
Organization Name:TULALIP TRIBES OF WASHINGTON
Other - Org Name:TULALIP TRIBES FAMILY & YOUTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR OF HEALTH SERVICE
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKU
Authorized Official - Middle Name:
Authorized Official - Last Name:SODHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-716-4511
Mailing Address - Street 1:6406 MARINE DR STE A
Mailing Address - Street 2:
Mailing Address - City:TULALIP
Mailing Address - State:WA
Mailing Address - Zip Code:98271
Mailing Address - Country:US
Mailing Address - Phone:360-716-4400
Mailing Address - Fax:360-716-5789
Practice Address - Street 1:2821 MISSION HILL RD
Practice Address - Street 2:
Practice Address - City:TULALIP
Practice Address - State:WA
Practice Address - Zip Code:98271
Practice Address - Country:US
Practice Address - Phone:360-716-4400
Practice Address - Fax:360-716-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 261QR0405X
WA31-0240-00101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1001570Medicaid
WA198754Medicaid
WA1993476Medicaid
WA1980952Medicaid