Provider Demographics
NPI:1114386711
Name:COUNSELING SERVICES OF WALLA WALLA
Entity Type:Organization
Organization Name:COUNSELING SERVICES OF WALLA WALLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTI
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW ACSW LICSW
Authorized Official - Phone:509-876-0100
Mailing Address - Street 1:PO BOX 3324
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0367
Mailing Address - Country:US
Mailing Address - Phone:509-876-0100
Mailing Address - Fax:509-876-0101
Practice Address - Street 1:127 E ROSE ST
Practice Address - Street 2:SUITE M
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-5009
Practice Address - Country:US
Practice Address - Phone:509-876-0100
Practice Address - Fax:509-876-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00006668305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1041C0700XOtherTAXONOMY
WALW00006668OtherLICSW LICENSE
WA603-575-701OtherUBI