MEDICARE: KILEY S RADICH MSW, LICSWA

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
1	104100000X	Social Worker	SC70074609	WA
2	101Y00000X	Counselor	CG61169626	WA
3	1041C0700X	Clinical Social Worker	SC70074609	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225619778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KILEY S RADICH MSW, LICSWA

Provider Business Mailing Address
First Line	:	PO BOX 2394
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-8455
Country	:	US
Telephone Number	:	360-200-5419
Fax Number	:	360-200-6736

Provider Business Practice Location Address
First Line	:	748 14TH AVE
Second Line	:
City	:	LONGVIEW
State	:	WA
Zip	:	98632-2315
Country	:	US
Telephone Number	:	360-200-5419
Fax Number	:	360-200-6736

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2021
Last Update Date	:	03/17/2026

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