Provider Demographics
NPI:1073142550
Name:KISH, DENNIS JR
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:KISH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 MARTIN WAY E STE 117
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5586
Mailing Address - Country:US
Mailing Address - Phone:360-413-6910
Mailing Address - Fax:
Practice Address - Street 1:6700 MARTIN WAY E STE 117
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-5586
Practice Address - Country:US
Practice Address - Phone:360-413-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WACO65015390390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)