Provider Demographics
NPI:1174570949
Name:WILLAPA COUNSELING CENTER
Entity type:Organization
Organization Name:WILLAPA COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATZEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-642-3783
Mailing Address - Street 1:2204 PACIFIC AVE N
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:WA
Mailing Address - Zip Code:98631-3300
Mailing Address - Country:US
Mailing Address - Phone:360-642-3787
Mailing Address - Fax:360-642-2096
Practice Address - Street 1:2204 PACIFIC AVE N
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:WA
Practice Address - Zip Code:98631-3300
Practice Address - Country:US
Practice Address - Phone:360-642-3787
Practice Address - Fax:360-642-2096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X, 261QP2300X
WAJ600618510261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1054667Medicaid
WA1054667Medicaid
WA1054667Medicaid