Provider Demographics
NPI:1588264022
Name:STORDAHL, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:STORDAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 SE 27TH ST UNIT 541
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3067
Mailing Address - Country:US
Mailing Address - Phone:425-246-7038
Mailing Address - Fax:206-420-3114
Practice Address - Street 1:7650 SE 27TH ST UNIT 541
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3067
Practice Address - Country:US
Practice Address - Phone:425-246-7038
Practice Address - Fax:206-420-3114
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician