Healthcare Provider Details

I. General information

NPI: 1720470859
Provider Name (Legal Business Name): LELAND KUYKENDALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S 2ND ST STE 2
RENTON WA
98057-2234
US

IV. Provider business mailing address

419 S 2ND ST STE 2
RENTON WA
98057-2234
US

V. Phone/Fax

Practice location:
  • Phone: 425-203-7215
  • Fax:
Mailing address:
  • Phone: 425-203-7215
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW 00004579
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: