Provider Demographics
NPI:1134373574
Name:C & R EXECUTIVES, LLC
Entity type:Organization
Organization Name:C & R EXECUTIVES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:LUDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:360-577-7442
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-0111
Mailing Address - Country:US
Mailing Address - Phone:360-577-7442
Mailing Address - Fax:
Practice Address - Street 1:309 OAK ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-2340
Practice Address - Country:US
Practice Address - Phone:360-577-7442
Practice Address - Fax:360-577-7904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA325/08 0535 00261QR0405X, 251B00000X
WA08 053500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2008862Medicaid