Basic Information
Provider Information
NPI: 1003002569
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CLIFTON
FirstName: KENNETH
MiddleName: E
NamePrefix:  
NameSuffix:  
Credential: MS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9040-A REID ST
Address2:  
City: JBLM
State: WA
PostalCode: 98431
CountryCode: US
TelephoneNumber: 2539686442
FaxNumber:  
Practice Location
Address1: 9922-B EAST JOHNSON ST
Address2:  
City: JBLM
State: WA
PostalCode: 984311100
CountryCode: US
TelephoneNumber: 2539684631
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/19/2007
LastUpdateDate: 08/24/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800XLH 60143083WAY Behavioral Health & Social Service ProvidersCounselorMental Health

No ID Information.


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