Basic Information
| Provider Information | |||||||||
| NPI: | 1104408525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRISTOL BAY AREA HEALTH CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BRISTOL BAY COUNSELING CENTER NEW STUYAHOK CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | DILLINGHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995760130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | 9078429250 | ||||||||
| Practice Location | |||||||||
| Address1: | WALLACE STREET | ||||||||
| Address2: | |||||||||
| City: | NEW STUYAHOK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078421230 | ||||||||
| FaxNumber: | 9078429250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2021 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | CATHY | ||||||||
| AuthorizedOfficialMiddleName: | LEEANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9078425201 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRISTOL BAY AREA HEALTH CORPORATION | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.