Provider Demographics
NPI:1285155366
Name:GREAT RIVERS BEHAVIORAL HEALTH ORGANIZATION
Entity type:Organization
Organization Name:GREAT RIVERS BEHAVIORAL HEALTH ORGANIZATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:BOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:360-795-5955
Mailing Address - Street 1:PO BOX 1447
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532
Mailing Address - Country:US
Mailing Address - Phone:360-795-5955
Mailing Address - Fax:360-740-8099
Practice Address - Street 1:57 W MAIN STREET
Practice Address - Street 2:SUITE 260
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-795-5955
Practice Address - Fax:360-740-8099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT RIVERS BEHAVIORAL HEALTH ORGANIZATI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603564565251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA200458Medicaid