Basic Information
| Provider Information | |||||||||
| NPI: | 1396012530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KLLALLAM COUSELING SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 NISBET RD | ||||||||
| Address2: | SEQU | ||||||||
| City: | SEQUIM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983827314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606818092 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1026 EAST FRONT ST. | ||||||||
| Address2: | #2 | ||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604524432 | ||||||||
| FaxNumber: | 3604524599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3604524432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CB00017145 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | CP00004528 | WA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | CP00004528 | 05 | WA | MEDICAID |