UPPER SKAGIT INDIAN TRIBE

Provider Demographics

• NPI: 1336129295
• Name: UPPER SKAGIT INDIAN TRIBE
• Entity Type: Organization
• Organization Name: UPPER SKAGIT INDIAN TRIBE
• Other - Org Name: UPPER SKAGIT TRIBAL CLINIC
• Other - Org Type: Other Name
• Authorized Official - Title/Position: TRIBAL VICE-CHAIRMAN
• Authorized Official - Prefix: MS
• Authorized Official - First Name: MARILYN
• Authorized Official - Middle Name: M
• Authorized Official - Last Name: SCOTT
• Authorized Official - Phone: 360-854-7039
• Mailing Address - Street 1: 25944 COMMUNITY PLAZA WAY
• Mailing Address - City: SEDRO WOOLLEY
• Mailing Address - State: WA
• Mailing Address - Zip Code: 98284-9721
• Mailing Address - Country: US
• Mailing Address - Phone: 360-854-7070
• Mailing Address - Fax: 360-854-7060
• Practice Address - Street 1: 25959 COMMUNITY PLAZA WAY
• Practice Address - City: SEDRO WOOLLEY
• Practice Address - State: WA
• Practice Address - Zip Code: 98284-9721
• Practice Address - Country: US
• Practice Address - Phone: 360-854-7070
• Practice Address - Fax: 360-854-7060
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: UPPER SKAGIT INDIAN TRIBE
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-01-18
• Last Update Date: 2019-07-23

Provider Licenses

State	License ID	Taxonomies
WA	CP00001654	101YA0400X
WA	;H00008445	103TC1900X
WA	RC00047287	104100000X
WA	DI00001414	133V00000X
WA	LP00022558	133V00000X
WA	MD00012663	208600000X, 208D00000X
WA		261QF0400X
WA	AP30006120	363LF0000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	261QF0400X	Ambulatory Health Care Facilities	Clinic/Center	Federally Qualified Health Center (FQHC)	Group - Single Specialty
No	101YA0400X	Behavioral Health & Social Service Providers	Counselor	Addiction (Substance Use Disorder)	Group - Single Specialty
No	103TC1900X	Behavioral Health & Social Service Providers	Psychologist	Counseling	Group - Single Specialty
No	104100000X	Behavioral Health & Social Service Providers	Social Worker		Group - Single Specialty
No	133V00000X	Dietary & Nutritional Service Providers	Dietitian, Registered		Group - Single Specialty
No	208600000X	Allopathic & Osteopathic Physicians	Surgery		Group - Single Specialty
No	208D00000X	Allopathic & Osteopathic Physicians	General Practice		Group - Single Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	1981323	Medicaid
WA	8024291	Medicaid
WA	9645573	Medicaid
WA	7084338	Medicaid
WA	1008805	Medicaid
WA	8466286	Medicaid
WA	1995281	Medicaid
WA	7203805	Medicaid
WA	H06929	Medicare UPIN
WA	9645573	Medicaid
WA	1981323	Medicaid
WA	7203805	Medicaid