Provider Demographics
NPI:1750825196
Name:CONNER, KANE (SUDP)
Entity Type:Individual
Prefix:MR
First Name:KANE
Middle Name:
Last Name:CONNER
Suffix:
Gender:M
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 KOALA DR
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9247
Mailing Address - Country:US
Mailing Address - Phone:509-826-6191
Mailing Address - Fax:509-826-3029
Practice Address - Street 1:1007 KOALA DR
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-826-6191
Practice Address - Fax:509-826-3029
Is Sole Proprietor?:No
Enumeration Date:2016-12-04
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60345463101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)