Provider Demographics
NPI:1467855353
Name:COMMUNITY HOUSE ON BROADWAY
Entity Type:Organization
Organization Name:COMMUNITY HOUSE ON BROADWAY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-200-5419
Mailing Address - Street 1:PO BOX 403
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7260
Mailing Address - Country:US
Mailing Address - Phone:360-200-5419
Mailing Address - Fax:360-200-6736
Practice Address - Street 1:748 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-200-5419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA313101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty