Provider Demographics
NPI:1063739738
Name:NOOKSACK CENTRAL MANAGEMENT SYSTEM
Entity type:Organization
Organization Name:NOOKSACK CENTRAL MANAGEMENT SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF TREATMENT SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:CCDCII, CHT
Authorized Official - Phone:360-966-7704
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0157
Mailing Address - Country:US
Mailing Address - Phone:360-966-7704
Mailing Address - Fax:360-966-4225
Practice Address - Street 1:3003 CABIN CREEK ROAD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:WA
Practice Address - Zip Code:98925
Practice Address - Country:US
Practice Address - Phone:425-508-3967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NOOKSACK TRIBES GENESIS II
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1993013Medicaid