Provider Demographics
NPI:1548750615
Name:ONE HEART WILD
Entity Type:Organization
Organization Name:ONE HEART WILD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:425-280-6508
Mailing Address - Street 1:12620 WILLAMETTE MERIDIAN RD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9701
Mailing Address - Country:US
Mailing Address - Phone:360-509-2948
Mailing Address - Fax:360-337-7433
Practice Address - Street 1:12620 WILLAMETTE MERIDIAN RD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9701
Practice Address - Country:US
Practice Address - Phone:360-509-2948
Practice Address - Fax:360-337-7433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALICSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2083710Medicaid