Healthcare Provider Details

I. General information

NPI: 1790346005
Provider Name (Legal Business Name): KRISTINE D ENKERUD MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 8TH ST
HOQUIAM WA
98550-2507
US

IV. Provider business mailing address

3857 MARTIN WAY E
OLYMPIA WA
98506-5268
US

V. Phone/Fax

Practice location:
  • Phone: 360-532-8629
  • Fax:
Mailing address:
  • Phone: 360-704-7170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60166769
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: