Provider Demographics
NPI:1760519060
Name:PENINSULA BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PENINSULA BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SISK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-457-0431
Mailing Address - Street 1:118 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6129
Mailing Address - Country:US
Mailing Address - Phone:360-457-0431
Mailing Address - Fax:360-457-0493
Practice Address - Street 1:118 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6129
Practice Address - Country:US
Practice Address - Phone:360-457-0431
Practice Address - Fax:360-457-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA251S00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9647298Medicaid
WA1980606Medicaid
WA7130883Medicaid
WA1980606Medicaid