Provider Demographics
NPI:1659806032
Name:CARITAS CRITICAL CASE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:CARITAS CRITICAL CASE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMOM-HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CCM
Authorized Official - Phone:206-207-9363
Mailing Address - Street 1:23205 SE BLACK NUGGET RD
Mailing Address - Street 2:APT J2
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-7326
Mailing Address - Country:US
Mailing Address - Phone:206-207-9363
Mailing Address - Fax:
Practice Address - Street 1:23205 SE BLACK NUGGET RD
Practice Address - Street 2:APT J2
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-7326
Practice Address - Country:US
Practice Address - Phone:206-207-9363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60625891163W00000X, 163WP0808X
NJ4219311163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty