Basic Information
| Provider Information | |||||||||
| NPI: | 1174276497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLOSKEY | ||||||||
| FirstName: | KEIRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | SUDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15314 NE DOLE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | YACOLT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986759521 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15314 NE DOLE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | YACOLT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986759521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602606300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2022 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO61040174 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2077844 | 05 | WA | MEDICAID |