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NPI Code Detail

MEDICARE: IVELISSE VALLELLANES SANTIAGO MA

MEDICARE: IVELISSE VALLELLANES SANTIAGO MA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health Counselor

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1CG60880238OTHERWAAGENCY AFFILIATED COUNSELO

General Provider Information

NPI Number : 1215410550
Entity Type Code : Individual
Provider Name (Legal Business Name) : IVELISSE VALLELLANES SANTIAGO MA
Provider Business Mailing Address
First Line : 1650 HONEYSUCKLE LN SW APT 22-304
Second Line :
City : TUMWATER
State : WA
Zip : 98512-6099
Country : US
Telephone Number : 939-777-6978
Fax Number :
Provider Business Practice Location Address
First Line : 627 W FRANKLIN ST
Second Line :
City : SHELTON
State : WA
Zip : 98584-3504
Country : US
Telephone Number : 360-763-5610
Fax Number : 360-462-0449
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/12/2018
Last Update Date : 09/12/2018

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Directions to “ IVELISSE VALLELLANES SANTIAGO MA” Practice Location

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