Provider Demographics
NPI:1750634275
Name:CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON
Entity Type:Organization
Organization Name:CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON
Other - Org Name:MATT TALBOT CENTER
Other - Org Type:Doing Business As
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 1:2313 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1711
Mailing Address - Country:US
Mailing Address - Phone:206-328-5771
Mailing Address - Fax:
Practice Address - Street 1:100 23RD AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2302
Practice Address - Country:US
Practice Address - Phone:206-328-5771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA17138600261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1055150Medicaid