Organization
EDUCATIONAL SERVICE DISTRICT 112
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SANDY MATHEWSON (PREVENTION CENTER DIRECTOR)
(360) 750-7505
Entity
Organization
Contact information
Practice address
2500 NE 65TH AVE, VANCOUVER, WA 98661-6812
(360) 750-7507
(360) 906-1010
Mailing address
2500 NE 65TH AVE, VANCOUVER, WA 98661-6812
(360) 750-7507
(360) 906-1010
Taxonomy
Speciality
Code
Description
License number
State
251300000X
Local Education Agency (LEA)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1995877
PROVIDER NUMBER USED WHEN BILLING TITLE XIX
WA
Enumeration date
07/17/2009
Last updated
07/17/2009
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