Provider Demographics
NPI:1467462952
Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WASHINGTON
Other - Org Name:PROVIDENCE ST PETER CHEMICAL DEPENDENCY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR REVENUE CYCLE MGMT SWSA
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NURMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-493-4081
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO/CREDENTIALING
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0246
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:4800 COLLEGE ST SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-4389
Practice Address - Country:US
Practice Address - Phone:360-456-7575
Practice Address - Fax:360-493-5088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3400017Medicaid
WAST3729OtherREGENCE
ALHO60IPMedicaid
WAST3729OtherREGENCE
WA=========OtherCIGNA
WAST3729OtherREGENCE
WA50-0143Medicare ID - Type Unspecified