Provider Demographics
NPI:1396012530
Name:KLLALLAM COUSELING SERVICES
Entity Type:Organization
Organization Name:KLLALLAM COUSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:CB00017145
Authorized Official - Phone:360-452-4432
Mailing Address - Street 1:73 NISBET RD
Mailing Address - Street 2:SEQU
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7314
Mailing Address - Country:US
Mailing Address - Phone:360-681-8092
Mailing Address - Fax:
Practice Address - Street 1:1026 EAST FRONT ST.
Practice Address - Street 2:#2
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362
Practice Address - Country:US
Practice Address - Phone:360-452-4432
Practice Address - Fax:360-452-4599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00004528261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP00004528Medicaid