Healthcare Provider Details

I. General information

NPI: 1083776892
Provider Name (Legal Business Name): KERRY L TROUT CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 W COURT ST 8
PASCO WA
99301
US

IV. Provider business mailing address

PO BOX 1323 515 W COURT ST
PASCO WA
99301
US

V. Phone/Fax

Practice location:
  • Phone: 509-528-6759
  • Fax: 509-544-0957
Mailing address:
  • Phone: 509-547-2204
  • Fax: 509-542-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00001561
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: