Provider Demographics
NPI:1043861743
Name:GREAT RIVERS BEHAVIORAL HEALTH ADMINISTRATIVE SERVICES ORG
Entity type:Organization
Organization Name:GREAT RIVERS BEHAVIORAL HEALTH ADMINISTRATIVE SERVICES ORG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TRINIDAD
Authorized Official - Middle Name:I
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-336-3237
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0210
Mailing Address - Country:US
Mailing Address - Phone:800-215-4460
Mailing Address - Fax:855-936-1291
Practice Address - Street 1:1723 KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531
Practice Address - Country:US
Practice Address - Phone:800-215-4460
Practice Address - Fax:855-936-1291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health