Provider Demographics
NPI:1578778189
Name:NOOKSACK CENTRAL MANAGEMENT SYSTEM
Entity Type:Organization
Organization Name:NOOKSACK CENTRAL MANAGEMENT SYSTEM
Other - Org Name:THE NOOKSACK HOPE BEHAVIORAL HEALTH PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:GOVERNMENTAL SERVICE EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-592-5176
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0157
Mailing Address - Country:US
Mailing Address - Phone:360-966-4150
Mailing Address - Fax:360-966-4111
Practice Address - Street 1:6760 MISSION RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9749
Practice Address - Country:US
Practice Address - Phone:360-966-4150
Practice Address - Fax:360-966-4111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOOKSACK CENTRAL MANAGMENT SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-14
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981018Medicaid