Healthcare Provider Details

I. General information

NPI: 1134373574
Provider Name (Legal Business Name): C & R EXECUTIVES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 OAK ST
KELSO WA
98626-2340
US

IV. Provider business mailing address

PO BOX 1077
KELSO WA
98626-0111
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-7442
  • Fax: 360-577-7904
Mailing address:
  • Phone: 360-577-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number08 053500
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number325/08 0535 00
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number325/08 0535 00
License Number StateWA

VIII. Authorized Official

Name: MRS. CATHY KAY LUDAHL
Title or Position: CLINICAL DIRECTOR
Credential: C.D.P.
Phone: 360-577-7442