Provider Demographics
NPI:1891109757
Name:KRALL, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KRALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9721 SPINNAKER BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8983
Mailing Address - Country:US
Mailing Address - Phone:360-516-6955
Mailing Address - Fax:
Practice Address - Street 1:31912 LITTLE BOSTON RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9700
Practice Address - Country:US
Practice Address - Phone:360-297-6331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60482281101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60482281OtherWASHINGTON STATE LICENSE NUMBER