Provider Demographics
| NPI: | 1124329669 |
|---|---|
| Name: | ILLAHEE HOME CORP |
| Entity type: | Organization |
| Organization Name: | ILLAHEE HOME CORP |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | KELLY |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | FROST |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | LMHC, SUDP |
| Authorized Official - Phone: | 360-676-4485 |
| Mailing Address - Street 1: | 1155 N STATE ST |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BELLINGHAM |
| Mailing Address - State: | WA |
| Mailing Address - Zip Code: | 98225-5037 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 360-676-4485 |
| Mailing Address - Fax: | 360-714-1294 |
| Practice Address - Street 1: | 1155 N STATE ST |
| Practice Address - Street 2: | |
| Practice Address - City: | BELLINGHAM |
| Practice Address - State: | WA |
| Practice Address - Zip Code: | 98225-5037 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 360-676-4485 |
| Practice Address - Fax: | 360-714-1294 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2010-11-16 |
| Last Update Date: | 2025-01-07 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101Y00000X | Behavioral Health & Social Service Providers | Counselor | Group - Multi-Specialty | |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling | Group - Multi-Specialty |
| No | 163WA0400X | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 175F00000X | Other Service Providers | Naturopath | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
| No | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| WA | 2200984 | Medicaid |
