Provider Demographics
NPI:1215410550
Name:VALLELLANES SANTIAGO, IVELISSE (MA)
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:VALLELLANES SANTIAGO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 HONEYSUCKLE LN SW APT 22-304
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6099
Mailing Address - Country:US
Mailing Address - Phone:939-777-6978
Mailing Address - Fax:
Practice Address - Street 1:627 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3504
Practice Address - Country:US
Practice Address - Phone:360-763-5610
Practice Address - Fax:360-462-0449
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60880238OtherAGENCY AFFILIATED COUNSELO