Basic Information
Provider Information | |||||||||
NPI: | 1770647778 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST RESOURCES II | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2708 WESTMOOR CT SW | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985025754 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3609438810 | ||||||||
FaxNumber: | 3609430931 | ||||||||
Practice Location | |||||||||
Address1: | 325 S 3RD STREET | ||||||||
Address2: |   | ||||||||
City: | SHELTON | ||||||||
State: | WA | ||||||||
PostalCode: | 985841735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604260890 | ||||||||
FaxNumber: | 3604264688 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 03/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEAL | ||||||||
AuthorizedOfficialFirstName: | DENNIS | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3609438810 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NORTHWEST RESOURCES II, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
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 |   | 324500000X |   |   | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   | 363LF0000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 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 | 363LP0808X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/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 | 1055102 | 05 | WA |   | MEDICAID |