Basic Information
| Provider Information | |||||||||
| NPI: | 1275024689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATWOOD | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | TYLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 LAKEWAY DR | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982255233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606762187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 515 LAKEWAY DR | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982255233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606762187 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2018 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60852907 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.