Provider Demographics
NPI:1194315333
Name:KANIESKI, CARLA JANE
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:JANE
Last Name:KANIESKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2088
Mailing Address - Country:US
Mailing Address - Phone:440-823-5287
Mailing Address - Fax:
Practice Address - Street 1:3616 118TH STREET CT NW
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-6867
Practice Address - Country:US
Practice Address - Phone:603-692-8173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician