Basic Information
| Provider Information | |||||||||
| NPI: | 1114447885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CKODRE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3857 MARTIN WAY E | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607047170 | ||||||||
| FaxNumber: | 3607094374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1275 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | TUMWATER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985126976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602921182 | ||||||||
| FaxNumber: | 3602921184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2017 | ||||||||
| LastUpdateDate: | 06/23/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 100188 | WA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | CG60150465 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100188 | 05 | WA | MEDICAID |