Basic Information
| Provider Information | |||||||||
| NPI: | 1699222547 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATHOLIC COMMUNITY SERVICES OF WESTERN WASHINGTON | ||||||||
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| OtherOrganizationName: | FBH PORTLAND | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 N 44TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984073715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537599544 | ||||||||
| FaxNumber: | 2537599512 | ||||||||
| Practice Location | |||||||||
| Address1: | 1904 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972021146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035178663 | ||||||||
| FaxNumber: | 5039434994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2016 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | THELEN | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE & POLICY ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 2537613898 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 76 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 274192 MCD | 05 | OR | MEDICAID |