Provider Demographics
NPI:1104024348
Name:PROVIDENCE HEALTH & SERVICE WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICE WASHINGTON
Other - Org Name:PROVIDENCE ADDICTIONS RECOVERY CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PAYOR CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6715
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-525-6778
Mailing Address - Fax:425-525-6700
Practice Address - Street 1:218-A MAIN STREET
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:WA
Practice Address - Zip Code:98356-0000
Practice Address - Country:US
Practice Address - Phone:360-496-6216
Practice Address - Fax:360-496-6232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602 399 531OtherUBI MASTER LICENSE
WA1250OtherBUSINESS LICENSE
WA602 399 531OtherUBI MASTER LICENSE
WA1250OtherBUSINESS LICENSE
WAG8802108Medicare PIN