Provider Demographics
NPI:1336518240
Name:LUCHMUN, KRIS
Entity type:Individual
Prefix:
First Name:KRIS
Middle Name:
Last Name:LUCHMUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:KRISNADUTH
Other - Middle Name:
Other - Last Name:LUCHMUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:921 14TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632
Mailing Address - Country:US
Mailing Address - Phone:360-423-0203
Mailing Address - Fax:360-577-0269
Practice Address - Street 1:2700 SIMPSON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520
Practice Address - Country:US
Practice Address - Phone:360-612-0012
Practice Address - Fax:360-218-5945
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60752761101YA0400X
WAMC 60150012101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health