Provider Demographics
NPI:1427640366
Name:REACH 907
Entity type:Organization
Organization Name:REACH 907
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-745-6200
Mailing Address - Street 1:777 N CRUSEY ST STE B109
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7100
Mailing Address - Country:US
Mailing Address - Phone:907-982-9645
Mailing Address - Fax:
Practice Address - Street 1:7335 E PALMER WASILLA HWY STE 2B
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-7710
Practice Address - Country:US
Practice Address - Phone:912-674-0417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1245901198OtherCLINICAL ASSOCIATE
AK1722585Medicaid
AK1518638469OtherCLINICAL ASSOCIATE
AK1407527351OtherCLINICAL ASSOCIATE
AK1707635Medicaid