Provider Demographics
NPI:1215440128
Name:PARENT TO PARENT SUPPORT PROGRAM OF THURSTON COUNTY
Entity type:Organization
Organization Name:PARENT TO PARENT SUPPORT PROGRAM OF THURSTON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARRUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-789-2332
Mailing Address - Street 1:1012 HOMANN DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2438
Mailing Address - Country:US
Mailing Address - Phone:360-352-1126
Mailing Address - Fax:360-918-8274
Practice Address - Street 1:1012 HOMANN DR SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2438
Practice Address - Country:US
Practice Address - Phone:360-352-1126
Practice Address - Fax:360-918-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2063227Medicaid