Provider Demographics
NPI:1922238526
Name:EDUCATIONAL SERVICE DISTRICT 112
Entity Type:Organization
Organization Name:EDUCATIONAL SERVICE DISTRICT 112
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREVENTION CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-750-7505
Mailing Address - Street 1:2500 NE 65TH AVE
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:360-750-7507
Mailing Address - Fax:360-906-1010
Practice Address - Street 1:2500 NE 65TH AVE
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:360-750-7507
Practice Address - Fax:360-906-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995877OtherPROVIDER NUMBER USED WHEN BILLING TITLE XIX