Provider Demographics
NPI:1376141929
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:ASST SEC FOR ENROLLENT/DIR REIMB
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 3290
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3290
Mailing Address - Country:US
Mailing Address - Phone:907-481-2000
Mailing Address - Fax:
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health