Basic Information
| Provider Information | |||||||||
| NPI: | 1215410550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALLELLANES SANTIAGO | ||||||||
| FirstName: | IVELISSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1650 HONEYSUCKLE LN SW APT 22-304 | ||||||||
| Address2: | |||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985126099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9397776978 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 627 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985843504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607635610 | ||||||||
| FaxNumber: | 3604620449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 09/12/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | CG60880238 | 01 | WA | AGENCY AFFILIATED COUNSELO | OTHER |