Provider Demographics
NPI:1093147589
Name:PROVIDENCE KODIAK ISLAND COUNSELING CENTER
Entity Type:Organization
Organization Name:PROVIDENCE KODIAK ISLAND COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MNANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMANIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:907-481-2400
Mailing Address - Street 1:717 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6416
Mailing Address - Country:US
Mailing Address - Phone:907-481-2400
Mailing Address - Fax:907-481-2419
Practice Address - Street 1:717 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6416
Practice Address - Country:US
Practice Address - Phone:907-481-2400
Practice Address - Fax:907-481-2419
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH AND SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK920162237251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management