Provider Demographics
NPI:1477115186
Name:HUSTON, DARRELL CHARLES KAWIKA
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:CHARLES KAWIKA
Last Name:HUSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 N 42ND ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-3611
Mailing Address - Country:US
Mailing Address - Phone:808-345-1754
Mailing Address - Fax:
Practice Address - Street 1:5209 N 42ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-3611
Practice Address - Country:US
Practice Address - Phone:808-345-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2021-07-27
Deactivation Date:2021-07-08
Deactivation Code:
Reactivation Date:2021-07-22
Provider Licenses
StateLicense IDTaxonomies
WAMC60968378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health