Basic Information
| Provider Information | |||||||||
| NPI: | 1124673157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIYAMOTO | ||||||||
| FirstName: | KRYSTYL | ||||||||
| MiddleName: | WYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NETTO | ||||||||
| OtherFirstName: | KRYSTYL | ||||||||
| OtherMiddleName: | WYNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 107 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5901 N LIDGERWOOD ST STE 115 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992081122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | 5093632762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2019 | ||||||||
| LastUpdateDate: | 10/14/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | SC60978657 | WA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.