Provider Demographics
NPI:1922570217
Name:VAN KOMEN, KATIE A (CDPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:A
Last Name:VAN KOMEN
Suffix:
Gender:F
Credentials:CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E LINCOLN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2348
Mailing Address - Country:US
Mailing Address - Phone:509-457-5653
Mailing Address - Fax:
Practice Address - Street 1:1206 N DOLARWAY RD STE 114
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-8392
Practice Address - Country:US
Practice Address - Phone:509-457-5653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60767403101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)