Basic Information
| Provider Information | |||||||||
| NPI: | 1174996649 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEAL | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | CDP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2708 WESTMOOR CT SW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985025754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609438810 | ||||||||
| FaxNumber: | 3609430931 | ||||||||
| Practice Location | |||||||||
| Address1: | 2708 WESTMOOR CT SW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985025754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609438810 | ||||||||
| FaxNumber: | 3609430931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP 00000104 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2001305 | 05 | WA | MEDICAID |