Provider Demographics
NPI:1255798237
Name:ELMENDORF, YVONNE CATHERINE STORM (CDP)
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:CATHERINE STORM
Last Name:ELMENDORF
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 ORCHARD ST W
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98467-3824
Mailing Address - Country:US
Mailing Address - Phone:253-414-7461
Mailing Address - Fax:253-627-8387
Practice Address - Street 1:5915 ORCHARD ST W
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98467-3824
Practice Address - Country:US
Practice Address - Phone:253-414-7461
Practice Address - Fax:253-627-8387
Is Sole Proprietor?:No
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60235071101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995208Medicaid