Provider Demographics
NPI:1073677605
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE ST. PETER CHEMICAL DEPENDENCY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REVENUE CYCLE MGMT SWSA
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NURMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-493-4081
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO/CREDENTIALING
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0246
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:506 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3517
Practice Address - Country:US
Practice Address - Phone:360-432-8692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2008-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1993062Medicaid
WA1993062Medicaid