Provider Demographics
NPI:1720176894
Name:COMMUNITY SERVICES NORTHWEST
Entity Type:Organization
Organization Name:COMMUNITY SERVICES NORTHWEST
Other - Org Name:MENTAL HEALTH NORTHWEST
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOREN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:360-397-8005
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1845
Mailing Address - Country:US
Mailing Address - Phone:360-397-8484
Mailing Address - Fax:360-397-8494
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:BLDG 17 SUITE B222
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8484
Practice Address - Fax:360-397-8494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602-237-149251S00000X
WA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1994615Medicaid
WA1994615Medicaid