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General NPI Number Information
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NPI Number | 1194595926
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Entity Type | Individual
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Provider Name | MALISSA KAUTZ CO61248684
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Gender | Female
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Dates
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Enumeration Date | 01/03/2024
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Last Update Date | 01/03/2024
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Provider Practice Location Address
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Address Line | 4301 S PINE ST STE 92
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City | TACOMA
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State | WA
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Zip | 98409-7259
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Country | US
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Telephone | 253-507-5334
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Fax | 253-330-5182
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Provider Business Mailing Address
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Address Line | 11127 10TH AVENUE CT E APT A303
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City | PARKLAND
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State | WA
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Zip | 98445-7081
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Country | US
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Telephone | 253-592-4509
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CO61248684
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License Number State | WA
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