Provider Demographics
NPI:1477390714
Name:DEFOREST, KRISTIN ELIZABETH (SWAICL)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ELIZABETH
Last Name:DEFOREST
Suffix:
Gender:F
Credentials:SWAICL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-1307
Mailing Address - Country:US
Mailing Address - Phone:360-640-1142
Mailing Address - Fax:
Practice Address - Street 1:2850 NW BUCKLIN HILL RD # 1036
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8513
Practice Address - Country:US
Practice Address - Phone:360-536-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC615683151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical