Basic Information
| Provider Information | |||||||||
| NPI: | 1669645073 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHOLIC COMMUNITY SERVICES WESTERN WASHINGTON | ||||||||
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| OtherOrganizationName: | CCS RECOVERY CENTER-SNOHOMISH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 LAKEWAY DR | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982255233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606762187 | ||||||||
| FaxNumber: | 3606762162 | ||||||||
| Practice Location | |||||||||
| Address1: | 2610 WETMORE AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982012927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252585270 | ||||||||
| FaxNumber: | 4252585275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 05/14/2014 | ||||||||
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| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3606762187 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MA, CDP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 31034400 | WA | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR0405X | 31085700 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 1994771 | 05 | WA | MEDICAID | 1990373 | 05 | WA | MEDICAID |