Provider Demographics
NPI:1538300413
Name:THORNTON KUKER, BETSI ELAINA SHARI (CDP)
Entity Type:Individual
Prefix:MS
First Name:BETSI
Middle Name:ELAINA SHARI
Last Name:THORNTON KUKER
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98322-0425
Mailing Address - Country:US
Mailing Address - Phone:360-440-0476
Mailing Address - Fax:
Practice Address - Street 1:2528 WHEATON WAY
Practice Address - Street 2:STE 106
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3305
Practice Address - Country:US
Practice Address - Phone:360-782-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACD00006271101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101YA0400XOtherWASHINGTON STATE