Provider Demographics
NPI:1710377940
Name:NAMI SOUTHWEST WASHINGTON
Entity Type:Organization
Organization Name:NAMI SOUTHWEST WASHINGTON
Other - Org Name:NAMI SW WA; NAMI CLARK COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:360-695-2823
Mailing Address - Street 1:5411 E MILL PLAIN BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7046
Mailing Address - Country:US
Mailing Address - Phone:360-695-2823
Mailing Address - Fax:360-823-1088
Practice Address - Street 1:5411 E MILL PLAIN BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7046
Practice Address - Country:US
Practice Address - Phone:360-695-2823
Practice Address - Fax:360-823-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2054003Medicaid