Provider Demographics
NPI:1821258682
Name:GILLUM, KRISTINA MARIE (REGISTERED COUNSELOR)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:GILLUM
Suffix:
Gender:F
Credentials:REGISTERED COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4906
Mailing Address - Country:US
Mailing Address - Phone:360-651-2366
Mailing Address - Fax:360-653-3119
Practice Address - Street 1:1227 2ND ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4906
Practice Address - Country:US
Practice Address - Phone:360-651-2366
Practice Address - Fax:360-653-3119
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00060088101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00060088OtherWASHINGTON STATE DEPARTMENT OF HEALTH