Provider Demographics
NPI:1487869095
Name:NOOKSACK CENTRAL MANAGEMENT SYSTEM
Entity type:Organization
Organization Name:NOOKSACK CENTRAL MANAGEMENT SYSTEM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GOVERNMENT SERVICE EXEC
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-952-5176
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:WA
Mailing Address - Zip Code:98244-0157
Mailing Address - Country:US
Mailing Address - Phone:360-966-7704
Mailing Address - Fax:360-966-4225
Practice Address - Street 1:6750 MISSION RD
Practice Address - Street 2:
Practice Address - City:EVERSON
Practice Address - State:WA
Practice Address - Zip Code:98247-9749
Practice Address - Country:US
Practice Address - Phone:360-966-7704
Practice Address - Fax:360-966-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1980911Medicaid