| Organization Name: | PROVIDENCE HEALTH & SERVICE WASHINGTON |
| NPI Number: | 1104024348 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NICOLE QUINN (PAYOR CREDENTIALING MANAGER) |
| Mailing Address: | 218-a Main Street Morton |
| State: | WA US |
| Postal Code: | 983560000 |
| Phone Number: | 3604966216 |
| Fax Number: | 3604966232 |
| NPI Enumeration Date: | 07/10/2007 |
| NPI Last Update Date: | 12/22/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |