Provider Demographics
NPI:1649391871
Name:PORT GAMBLE S'KLALLAM SOCIAL SERVICES
Entity Type:Organization
Organization Name:PORT GAMBLE S'KLALLAM SOCIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CENTER BUSINESS OFFICE MANAG
Authorized Official - Prefix:
Authorized Official - First Name:KERSTIN
Authorized Official - Middle Name:MARGARETA
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-297-9601
Mailing Address - Street 1:32014 LITTLE BOSTON RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9734
Mailing Address - Country:US
Mailing Address - Phone:360-297-9601
Mailing Address - Fax:360-297-9614
Practice Address - Street 1:32014 LITTLE BOSTON RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9734
Practice Address - Country:US
Practice Address - Phone:360-297-9601
Practice Address - Fax:360-297-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981125Medicaid