Provider Demographics
NPI:1518415322
Name:GILES, KELVIN R (CHEMICAL DEPENDENCY)
Entity Type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:R
Last Name:GILES
Suffix:
Gender:M
Credentials:CHEMICAL DEPENDENCY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17337 RESERVATION RD
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-8802
Mailing Address - Country:US
Mailing Address - Phone:360-466-1024
Mailing Address - Fax:360-466-7364
Practice Address - Street 1:17337 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8802
Practice Address - Country:US
Practice Address - Phone:360-466-1024
Practice Address - Fax:360-466-7364
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00060166467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)