Basic Information
| Provider Information | |||||||||
| NPI: | 1477601789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | RAE VANDERMARK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7825 CANTERWOOD DR SE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985136520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604593447 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1800 COOPER POINT RD SW | ||||||||
| Address2: | BLDG 17 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985021178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603524602 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PY00002568 | WA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | PY00002568 | 01 | WA | STATE LICENSE | OTHER | 0157189 | 01 | WA | L AND I | OTHER |