Provider Demographics
NPI:1568058527
Name:ELDRED, WILLIAM L (SUDPT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:ELDRED
Suffix:
Gender:M
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MORAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2667
Mailing Address - Country:US
Mailing Address - Phone:509-735-6900
Mailing Address - Fax:509-735-6914
Practice Address - Street 1:415 N MORAIN ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2667
Practice Address - Country:US
Practice Address - Phone:509-735-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60960409101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO60960409Medicaid