Individual
STACY RAEANN WIRKKALA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
SUDPT
Contact information
Practice address
404 W MAIN ST, KELSO, WA 98626-1118
(360) 423-2806
Mailing address
190 GRASSETH POSTON RD, LONGVIEW, WA 98632-9147
(360) 703-4251
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
CO61077791
WA
Other
Enumeration date
01/30/2022
Last updated
07/01/2023
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