Provider Demographics
NPI:1861045197
Name:SACRED DREAMS COUNSELING CENTER
Entity Type:Organization
Organization Name:SACRED DREAMS COUNSELING CENTER
Other - Org Name:SACRED DREAMS COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:360-385-1350
Mailing Address - Street 1:PO BOX 1014
Mailing Address - Street 2:
Mailing Address - City:CHIMACUM
Mailing Address - State:WA
Mailing Address - Zip Code:98325-1014
Mailing Address - Country:US
Mailing Address - Phone:603-385-1350
Mailing Address - Fax:360-385-9600
Practice Address - Street 1:11237 RHODY DR STE A
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9749
Practice Address - Country:US
Practice Address - Phone:360-385-1350
Practice Address - Fax:360-385-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-16
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA214041Medicaid
WA1467834135Medicaid