Healthcare Provider Details

I. General information

NPI: 1164089132
Provider Name (Legal Business Name): KEVIN BRYANT PATTERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/19/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3510 STEELHAMMER DR
CENTRALIA WA
98531-4551
US

IV. Provider business mailing address

3510 STEELHAMMER DR
CENTRALIA WA
98531-4551
US

V. Phone/Fax

Practice location:
  • Phone: 360-623-8020
  • Fax:
Mailing address:
  • Phone: 360-623-8020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60944441
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: