Provider Demographics
NPI:1588747059
Name:NORTHWEST INDIAN TREATMENT CENTER
Entity type:Organization
Organization Name:NORTHWEST INDIAN TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-470-1474
Mailing Address - Street 1:308 EAST YOUNG STREET
Mailing Address - Street 2:BOX 477
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:308 E. YOUNG STREET
Practice Address - Street 2:BOX 477
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-482-2674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARTF1034324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1990696Medicaid
WA1981026Medicaid