Provider Demographics
NPI:1013098219
Name:COLLINS, KEVIN DEAN (CDP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DEAN
Last Name:COLLINS
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4020
Mailing Address - Country:US
Mailing Address - Phone:360-452-4432
Mailing Address - Fax:360-452-4599
Practice Address - Street 1:1026 E 1ST ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4020
Practice Address - Country:US
Practice Address - Phone:360-452-4432
Practice Address - Fax:360-452-4599
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001181101YA0400X
WARC00017145101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1981018Medicaid