Provider Demographics
NPI:1225532849
Name:CRADLESTONE, LLC
Entity Type:Organization
Organization Name:CRADLESTONE, LLC
Other - Org Name:CRADLESTONE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:WIEGENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:AS, BA, MS
Authorized Official - Phone:360-682-5519
Mailing Address - Street 1:PO BOX 891
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-0891
Mailing Address - Country:US
Mailing Address - Phone:360-682-5519
Mailing Address - Fax:
Practice Address - Street 1:780 SE BAYSHORE DR # 201
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5701
Practice Address - Country:US
Practice Address - Phone:360-682-5519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA604194142261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health