Provider Demographics
NPI:1790008928
Name:EDUCATIONAL SERVICE DISTRICT 112
Entity Type:Organization
Organization Name:EDUCATIONAL SERVICE DISTRICT 112
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUDGET ANALYST
Authorized Official - Prefix:MR
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOTTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-750-7500
Mailing Address - Street 1:2500 NE 65 AVENUE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-6812
Mailing Address - Country:US
Mailing Address - Phone:360-750-7500
Mailing Address - Fax:360-906-1010
Practice Address - Street 1:2500 NE 65 AVENUE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6812
Practice Address - Country:US
Practice Address - Phone:360-750-7500
Practice Address - Fax:360-906-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X, 251B00000X, 261QM0801X
WA261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1996008OtherCURRENT PROVIDER NUMBER TO BE USED WITH NPI