Provider Demographics
NPI:1154974558
Name:COLLINS, KENNETH ROY (MSW)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROY
Last Name:COLLINS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 REINIER RD
Mailing Address - Street 2:
Mailing Address - City:NORDLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98358-9675
Mailing Address - Country:US
Mailing Address - Phone:360-531-2432
Mailing Address - Fax:
Practice Address - Street 1:400 REINIER RD
Practice Address - Street 2:
Practice Address - City:NORDLAND
Practice Address - State:WA
Practice Address - Zip Code:98358-9675
Practice Address - Country:US
Practice Address - Phone:360-531-2432
Practice Address - Fax:360-860-6550
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000093551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALW00009355OtherDEPARTMENT OF HEALTH