Provider Demographics
NPI:1508919168
Name:STILLAGUAMISH BEHAVIORAL HEALTH PROGRAMS
Entity Type:Organization
Organization Name:STILLAGUAMISH BEHAVIORAL HEALTH PROGRAMS
Other - Org Name:STILLAGUAMISH BEHAVIORAL HEALTH PROGRAMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CO-EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:360-572-3033
Mailing Address - Street 1:5700 172ND ST NE SUITE B
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223
Mailing Address - Country:US
Mailing Address - Phone:360-435-3985
Mailing Address - Fax:360-435-7941
Practice Address - Street 1:5700 172ND ST NE SUITE B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-435-3985
Practice Address - Fax:360-435-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1992619Medicaid