Provider Demographics
NPI:1417397951
Name:CROSSROADS TREATMENT CENTER, INC.
Entity Type:Organization
Organization Name:CROSSROADS TREATMENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CDPT INTERN
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:WHITTY-SANDAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CDPT
Authorized Official - Phone:850-218-0752
Mailing Address - Street 1:10828 GRAVELLY LAKE DR SW STE 204
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1346
Mailing Address - Country:US
Mailing Address - Phone:253-473-7474
Mailing Address - Fax:253-474-9724
Practice Address - Street 1:10828 GRAVELLY LAKE DR SW STE 204
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1346
Practice Address - Country:US
Practice Address - Phone:253-473-7474
Practice Address - Fax:253-474-9724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60367121101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty