Provider Demographics
NPI:1235506189
Name:PERSONAL SERVICE PROVIDERS
Entity Type:Organization
Organization Name:PERSONAL SERVICE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:360-538-1540
Mailing Address - Street 1:720 LEVEE ST
Mailing Address - Street 2:
Mailing Address - City:HOQUIAM
Mailing Address - State:WA
Mailing Address - Zip Code:98550-2517
Mailing Address - Country:US
Mailing Address - Phone:360-538-1540
Mailing Address - Fax:
Practice Address - Street 1:720 LEVEE ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-2517
Practice Address - Country:US
Practice Address - Phone:360-538-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIHS.FS.00000408253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111848801Medicaid