Provider Demographics
NPI:1336611177
Name:PADILLA, ALFRED (MA, DCR, AAC)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:PADILLA
Suffix:
Gender:M
Credentials:MA, DCR, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5000
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-5000
Mailing Address - Country:US
Mailing Address - Phone:360-397-8198
Mailing Address - Fax:
Practice Address - Street 1:1601 E 4TH PLAIN BLVD BLDG 17
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3717
Practice Address - Country:US
Practice Address - Phone:360-397-8198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60211393101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health