Provider Demographics
NPI:1851819833
Name:KILLGORE, BRIA MOIRA (MSW, CHES)
Entity Type:Individual
Prefix:
First Name:BRIA
Middle Name:MOIRA
Last Name:KILLGORE
Suffix:
Gender:F
Credentials:MSW, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:921 14TH AVENUE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-423-2311
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60806216101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2097771Medicaid