Provider Demographics
NPI:1477601789
Name:POWELL, KRISTINE RAE VANDERMARK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:RAE VANDERMARK
Last Name:POWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 CANTERWOOD DR SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-6520
Mailing Address - Country:US
Mailing Address - Phone:360-459-3447
Mailing Address - Fax:
Practice Address - Street 1:1800 COOPER POINT RD SW
Practice Address - Street 2:BLDG 17
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1178
Practice Address - Country:US
Practice Address - Phone:360-352-4602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002568103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPY00002568OtherSTATE LICENSE
WA0157189OtherL AND I