Provider Demographics
NPI:1073766317
Name:KIC/THC BEHAVIORAL HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:KIC/THC BEHAVIORAL HEALTH DEPARTMENT
Other - Org Name:KIC SOCIAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:907-228-4926
Mailing Address - Street 1:2960 TONGASS AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-4917
Mailing Address - Fax:907-228-4920
Practice Address - Street 1:2960 TONGASS AVE FL 1
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-4917
Practice Address - Fax:907-228-4920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KETCHIKAN INDIAN COMMUNITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-30
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDA2696Medicaid