Provider Demographics
NPI:1225039811
Name:GREATER LAKES MENTAL HEALTH FOUNDATION INC
Entity Type:Organization
Organization Name:GREATER LAKES MENTAL HEALTH FOUNDATION INC
Other - Org Name:GREATER LAKES MENTAL HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:CZERWINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-620-5134
Mailing Address - Street 1:9330 59TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2858
Mailing Address - Country:US
Mailing Address - Phone:253-581-7020
Mailing Address - Fax:253-620-5149
Practice Address - Street 1:9330 59TH AVE SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2858
Practice Address - Country:US
Practice Address - Phone:253-581-7020
Practice Address - Fax:253-620-5149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-03
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1043327Medicaid
WA1984301Medicaid
WA7029689Medicaid
WA9633157Medicaid
WA9633157Medicaid