Provider Demographics
NPI:1083487102
Name:KOELSCH, KEVIN ROSS (SUDPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROSS
Last Name:KOELSCH
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 E HIGHWAY 101
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-9068
Mailing Address - Country:US
Mailing Address - Phone:360-452-4062
Mailing Address - Fax:360-452-4189
Practice Address - Street 1:3430 E HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-9068
Practice Address - Country:US
Practice Address - Phone:360-452-4062
Practice Address - Fax:360-452-4189
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61488824101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)