Provider Demographics
NPI:1710287479
Name:WESTERN STATE HOSPITAL
Entity Type:Organization
Organization Name:WESTERN STATE HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC SOCIALWORKER SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELSO
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:253-756-2966
Mailing Address - Street 1:9601 STEILACOOM BLVD SW
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98498-7212
Mailing Address - Country:US
Mailing Address - Phone:253-756-3971
Mailing Address - Fax:
Practice Address - Street 1:9601 STEILACOOM BLVD SW
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98498-7212
Practice Address - Country:US
Practice Address - Phone:253-756-3971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60040431283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital