Basic Information
Provider Information | |||||||||
NPI: | 1225039811 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREATER LAKES MENTAL HEALTH FOUNDATION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GREATER LAKES MENTAL HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9330 59TH AVE SW | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 984992858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535817020 | ||||||||
FaxNumber: | 2536205149 | ||||||||
Practice Location | |||||||||
Address1: | 9330 59TH AVE SW | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 984992858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535817020 | ||||||||
FaxNumber: | 2536205149 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/03/2005 | ||||||||
LastUpdateDate: | 01/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CZERWINSKI | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | GLENN | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 2536205134 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 320800000X |   |   | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 1043327 | 05 | WA |   | MEDICAID |