Provider Demographics
NPI:1568137370
Name:PILGRIM BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:PILGRIM BEHAVIORAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:PILGRIM
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:505-501-8293
Mailing Address - Street 1:46 VILLAGE WAY # 107
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-5102
Mailing Address - Country:US
Mailing Address - Phone:505-501-8293
Mailing Address - Fax:505-521-5149
Practice Address - Street 1:4405 7TH AVENUE STE 200
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503
Practice Address - Country:US
Practice Address - Phone:505-501-8293
Practice Address - Fax:505-521-5149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44002335Medicaid
NM1568137370Medicaid
HI007433Medicaid