Healthcare Provider Details

I. General information

NPI: 1023596129
Provider Name (Legal Business Name): LAVONNA KOFSTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 07/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD BLDG 17
VANCOUVER WA
98661-3717
US

IV. Provider business mailing address

PO BOX 1845
VANCOUVER WA
98668-1845
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8484
  • Fax: 360-397-8494
Mailing address:
  • Phone: 360-397-8484
  • Fax: 360-397-8494

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: