Provider Demographics
NPI:1194595926
Name:KAUTZ, MALISSA (CO61248684)
Entity type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:KAUTZ
Suffix:
Gender:F
Credentials:CO61248684
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11127 10TH AVENUE CT E APT A303
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98445-7081
Mailing Address - Country:US
Mailing Address - Phone:253-592-4509
Mailing Address - Fax:
Practice Address - Street 1:4301 S PINE ST STE 92
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7259
Practice Address - Country:US
Practice Address - Phone:253-507-5334
Practice Address - Fax:253-330-5182
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61248684101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)