Provider Demographics
NPI:1548384126
Name:TSAPOWUM-CHEHALIS TRIBAL CHEMICAL DEPENDANCY
Entity Type:Organization
Organization Name:TSAPOWUM-CHEHALIS TRIBAL CHEMICAL DEPENDANCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:POCKAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-858-1660
Mailing Address - Street 1:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:OAKVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98568-0570
Mailing Address - Country:US
Mailing Address - Phone:360-858-1660
Mailing Address - Fax:360-273-2723
Practice Address - Street 1:420 HOWANUT RD
Practice Address - Street 2:
Practice Address - City:OAKVILLE
Practice Address - State:WA
Practice Address - Zip Code:98568
Practice Address - Country:US
Practice Address - Phone:360-858-1660
Practice Address - Fax:360-273-2723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA14 0096 00171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14 0096 00OtherADATSA APPROVAL NUMBER
WA1992684Medicaid