Provider Demographics
NPI:1699222547
Name:CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON
Entity Type:Organization
Organization Name:CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON
Other - Org Name:FBH PORTLAND
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPLIANCE & POLICY ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-761-3898
Mailing Address - Street 1:5410 N 44TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-3715
Mailing Address - Country:US
Mailing Address - Phone:253-759-9544
Mailing Address - Fax:253-759-9512
Practice Address - Street 1:1904 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1146
Practice Address - Country:US
Practice Address - Phone:503-517-8663
Practice Address - Fax:503-943-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA76261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274192 MCDMedicaid