Provider Demographics
NPI:1922040526
Name:BLUE MOUNTAIN COUNSELING OF COLUMBIA COUNTY
Entity type:Organization
Organization Name:BLUE MOUNTAIN COUNSELING OF COLUMBIA COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:509-382-1164
Mailing Address - Street 1:221 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328-1317
Mailing Address - Country:US
Mailing Address - Phone:509-382-1164
Mailing Address - Fax:509-382-1166
Practice Address - Street 1:221 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328-1317
Practice Address - Country:US
Practice Address - Phone:509-382-1164
Practice Address - Fax:509-382-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA223261QM0801X
WAG8809077261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8809077Medicare ID - Type UnspecifiedGROUP NUMBER