Healthcare Provider Details

I. General information

NPI: 1861212367
Provider Name (Legal Business Name): EITAN CODISH
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24415 NE 219TH ST
BATTLE GROUND WA
98604-9694
US

IV. Provider business mailing address

24415 NE 219TH ST
BATTLE GROUND WA
98604-9694
US

V. Phone/Fax

Practice location:
  • Phone: 503-808-0373
  • Fax:
Mailing address:
  • Phone: 503-808-0373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR10171
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: