Healthcare Provider Details

I. General information

NPI: 1265982763
Provider Name (Legal Business Name): ILLAHEE HOME CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N STATE ST STE 522
BELLINGHAM WA
98225-7067
US

IV. Provider business mailing address

1155 N STATE ST STE 522
BELLINGHAM WA
98225-7067
US

V. Phone/Fax

Practice location:
  • Phone: 360-676-4485
  • Fax: 360-714-1294
Mailing address:
  • Phone: 360-676-4485
  • Fax: 360-714-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCO60545681
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY RYAN FROST
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 360-676-4485