Provider Demographics
NPI:1801117056
Name:SELF, SAVANNAH N
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:N
Last Name:SELF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 W UMPTANUM RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-8958
Mailing Address - Country:US
Mailing Address - Phone:509-899-4650
Mailing Address - Fax:
Practice Address - Street 1:820 W UMPTANUM RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8958
Practice Address - Country:US
Practice Address - Phone:509-899-4650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60174371171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator