Provider Demographics
NPI:1437626157
Name:CANADA, RHONDA GAIL (CP60776314)
Entity Type:Individual
Prefix:MS
First Name:RHONDA
Middle Name:GAIL
Last Name:CANADA
Suffix:
Gender:F
Credentials:CP60776314
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9179
Mailing Address - Country:US
Mailing Address - Phone:360-876-9430
Mailing Address - Fax:360-876-7310
Practice Address - Street 1:1415 LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-9179
Practice Address - Country:US
Practice Address - Phone:360-876-9430
Practice Address - Fax:360-876-7310
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60776314101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACP60776314OtherDEPARTMENT OF HEALTH