Provider Demographics
NPI:1235689381
Name:SWINOMISH INDIAN TRIBAL COMMUNITY
Entity Type:Organization
Organization Name:SWINOMISH INDIAN TRIBAL COMMUNITY
Other - Org Name:SWINOMISH WELLNESS PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-588-2735
Mailing Address - Street 1:17337 RESERVATION RD
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-8802
Mailing Address - Country:US
Mailing Address - Phone:360-466-1024
Mailing Address - Fax:360-466-7634
Practice Address - Street 1:17337 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8802
Practice Address - Country:US
Practice Address - Phone:360-466-1024
Practice Address - Fax:360-466-7634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60166467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60166467OtherWASHINGTON STATE