Provider Demographics
NPI:1790257244
Name:HULL-GINGREY, KYLEE ANN (CDP)
Entity Type:Individual
Prefix:MRS
First Name:KYLEE
Middle Name:ANN
Last Name:HULL-GINGREY
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 1:614 DIVISION ST # MS -19
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4614
Mailing Address - Country:US
Mailing Address - Phone:360-337-5738
Mailing Address - Fax:360-337-4704
Practice Address - Street 1:614 DIVISION ST # MS -19
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4614
Practice Address - Country:US
Practice Address - Phone:360-337-5738
Practice Address - Fax:360-337-4704
Is Sole Proprietor?:No
Enumeration Date:2018-12-21
Last Update Date:2019-11-07
Deactivation Date:2019-07-25
Deactivation Code:
Reactivation Date:2019-11-07
Provider Licenses
StateLicense IDTaxonomies
WACP60669053101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA090515Medicaid