Organization
PROVIDENCE HEALTH & SERVICES WASHINGTON
Active
Other names
PROVIDENCE KODIAK ISLAND COUNSELING CENTER
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DONALD WAYNE ANDERSON JR. (ASSISTANT SECRETARY OF ENROLLMENTS)
(425) 358-9786
Entity
Organization
Contact information
Practice address
1818 E REZANOF DR, KODIAK, AK 99615-6505
(907) 481-2400
(907) 481-2419
Mailing address
PO BOX 3290, PORTLAND, OR 97208-3290
(907) 486-9500
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
297340
AK
1041C0700X
Clinical Social Worker
297340
AK
171M00000X
Case Manager/Care Coordinator
297340
AK
2084P0800X
Psychiatry Physician
297340
AK
251S00000X
Community/Behavioral Health Agency
Primary
297340
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
MH 2237 & DA2237
—
AK
Enumeration date
08/09/2006
Last updated
05/15/2025
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