Healthcare Provider Details

I. General information

NPI: 1063819175
Provider Name (Legal Business Name): IBRAHIM KURDIEH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE SUITE B
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

2621 NE 134TH ST STE 340
VANCOUVER WA
98686-3036
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-8600
  • Fax: 360-636-7372
Mailing address:
  • Phone: 360-450-0140
  • Fax: 877-343-0535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 60523286
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: