Healthcare Provider Details

I. General information

NPI: 1487214409
Provider Name (Legal Business Name): MACHELLE DENISE KURTZ I CP 61083985
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FIR ST
LONGVIEW WA
98632-2544
US

IV. Provider business mailing address

900 FIR ST
LONGVIEW WA
98632-2544
US

V. Phone/Fax

Practice location:
  • Phone: 360-575-3316
  • Fax: 360-423-7813
Mailing address:
  • Phone: 360-575-3316
  • Fax: 360-423-7813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61278581
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60613489
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: