Provider Demographics
NPI:1255571063
Name:CAPITAL CLUBHOUSE
Entity type:Organization
Organization Name:CAPITAL CLUBHOUSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:RACHELE
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-357-2582
Mailing Address - Street 1:1000 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-1433
Mailing Address - Country:US
Mailing Address - Phone:360-357-2582
Mailing Address - Fax:360-357-2821
Practice Address - Street 1:1000 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1433
Practice Address - Country:US
Practice Address - Phone:360-357-2582
Practice Address - Fax:360-357-2821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
WA601-217-168251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2002974Medicaid