Provider Demographics
NPI:1700081775
Name:SWINOMISH TRIBAL MENTAL HEALTH PROGRAM
Entity Type:Organization
Organization Name:SWINOMISH TRIBAL MENTAL HEALTH PROGRAM
Other - Org Name:SWINOMISH TRIBAL COMMUNITY
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BACKLUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-466-1275
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0388
Mailing Address - Country:US
Mailing Address - Phone:360-466-1275
Mailing Address - Fax:360-466-7301
Practice Address - Street 1:17395 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8802
Practice Address - Country:US
Practice Address - Phone:360-466-1275
Practice Address - Fax:360-466-7301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SWINOMISH TRIBAL COMMUNITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-19
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981281Medicaid