Provider Demographics
NPI:1447555644
Name:PORT GARDNER BAY RECOVERY
Entity type:Organization
Organization Name:PORT GARDNER BAY RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCABE
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:425-252-4656
Mailing Address - Street 1:2722 COLBY AVE
Mailing Address - Street 2:SUITE 424
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3557
Mailing Address - Country:US
Mailing Address - Phone:425-252-4656
Mailing Address - Fax:425-252-4308
Practice Address - Street 1:2722 COLBY AVE
Practice Address - Street 2:SUITE 424
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3557
Practice Address - Country:US
Practice Address - Phone:425-252-4656
Practice Address - Fax:425-252-4308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA31114400251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health