Basic Information
Provider Information | |||||||||
NPI: | 1386939593 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CONSEJO COUNSELING AND REFERRAL SERVICE - KENT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3808 S ANGELINE ST | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981181712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2064614880 | ||||||||
FaxNumber: | 2064616989 | ||||||||
Practice Location | |||||||||
Address1: | 515 W HARRISON ST STE 109 | ||||||||
Address2: |   | ||||||||
City: | KENT | ||||||||
State: | WA | ||||||||
PostalCode: | 980324403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2538569000 | ||||||||
FaxNumber: | 2535206647 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/15/2011 | ||||||||
LastUpdateDate: | 07/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAREDES | ||||||||
AuthorizedOfficialFirstName: | MARIO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2064614880 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | WA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 149500 | 01 | WA | DBHR SITE LICENSE ID | OTHER |