Provider Demographics
NPI:1932286101
Name:CASCADIA ADDICTION-BOUNTIFUL LIFE TREATMENT CENTER PLLC
Entity type:Organization
Organization Name:CASCADIA ADDICTION-BOUNTIFUL LIFE TREATMENT CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TIKUNOFF
Authorized Official - Suffix:JR
Authorized Official - Credentials:SUDP
Authorized Official - Phone:360-373-0155
Mailing Address - Street 1:2817 WHEATON WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3440
Mailing Address - Country:US
Mailing Address - Phone:360-373-0155
Mailing Address - Fax:360-373-0258
Practice Address - Street 1:2817 WHEATON WAY STE 205
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3440
Practice Address - Country:US
Practice Address - Phone:360-373-0155
Practice Address - Fax:360-373-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002242101YA0400X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995612Medicaid