Provider Demographics
NPI:1669508537
Name:NORTHWEST INDIAN TREATMENT CENTER
Entity Type:Organization
Organization Name:NORTHWEST INDIAN TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-470-1474
Mailing Address - Street 1:308 E. YOUNG ST.
Mailing Address - Street 2:BOX 477
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 SE WHITENER RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7747
Practice Address - Country:US
Practice Address - Phone:360-470-1474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA23037400261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981026Medicaid