Provider Demographics
NPI:1609094838
Name:CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Entity Type:Organization
Organization Name:CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Other - Org Name:MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-634-2783
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0150
Mailing Address - Country:US
Mailing Address - Phone:509-634-2783
Mailing Address - Fax:509-634-2781
Practice Address - Street 1:21 COLVILLE STREET
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155-0150
Practice Address - Country:US
Practice Address - Phone:509-634-2783
Practice Address - Fax:509-634-2781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONFEDERATED TRIBES OF THE COLVILLE RESERVATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1980812261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1980812Medicaid