Basic Information
| Provider Information | |||||||||
| NPI: | 1982134136 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOCOUREK | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603539494 | ||||||||
| FaxNumber: | 3603539440 | ||||||||
| Practice Location | |||||||||
| Address1: | 15455 65TH AVE S | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981882534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067215170 | ||||||||
| FaxNumber: | 3603539440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2017 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 60843692 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.