Provider Demographics
NPI:1265102255
Name:KAIPOV, MYRNA JUDITH
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:JUDITH
Last Name:KAIPOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:JUDITH
Other - Last Name:DALAKISHVILI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N HOWARD ST STE W
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0508
Mailing Address - Country:US
Mailing Address - Phone:253-448-3190
Mailing Address - Fax:
Practice Address - Street 1:4232 6TH AVE SE STE 101
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1081
Practice Address - Country:US
Practice Address - Phone:253-583-2825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
WASA61410542104100000X
390200000X
WASC61520842104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program