Healthcare Provider Details

I. General information

NPI: 1215410550
Provider Name (Legal Business Name): IVELISSE VALLELLANES SANTIAGO MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 W FRANKLIN ST
SHELTON WA
98584-3504
US

IV. Provider business mailing address

1650 HONEYSUCKLE LN SW APT 22-304
TUMWATER WA
98512-6099
US

V. Phone/Fax

Practice location:
  • Phone: 360-763-5610
  • Fax: 360-462-0449
Mailing address:
  • Phone: 939-777-6978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: