Healthcare Provider Details

I. General information

NPI: 1871296103
Provider Name (Legal Business Name): KOKMADUWE PALITHA LIYANAGE B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 03/24/2023
Certification Date: 12/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 PACIFIC AVE STE C3
TACOMA WA
98408-7423
US

IV. Provider business mailing address

941 DAVIS PL S
SEATTLE WA
98144-2939
US

V. Phone/Fax

Practice location:
  • Phone: 253-363-8853
  • Fax: 253-292-1919
Mailing address:
  • Phone: 206-981-6265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number471388664
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: