Basic Information
| Provider Information | |||||||||
| NPI: | 1427488113 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST RESOURCES II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2708 WESTMOOR CT SW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985025754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609438810 | ||||||||
| FaxNumber: | 3609430931 | ||||||||
| Practice Location | |||||||||
| Address1: | 3773-A MARTIN WAY E, STE 105 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606887312 | ||||||||
| FaxNumber: | 3606887318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2013 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3609438810 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CDP, C.AD | ||||||||
| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 251S00000X | N | Agencies | Community/Behavioral Health | 363LF0000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 101Y00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 363LP2300X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 101YA0400X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | N06671 | 01 | WA | REGENCE BLUE SHIELD | OTHER | 2041727 | 05 | WA | MEDICAID |