Provider Demographics
NPI:1265982763
Name:ILLAHEE HOME CORP
Entity type:Organization
Organization Name:ILLAHEE HOME CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:360-676-4485
Mailing Address - Street 1:1130 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5014
Mailing Address - Country:US
Mailing Address - Phone:360-676-4485
Mailing Address - Fax:360-714-1294
Practice Address - Street 1:1130 N STATE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5014
Practice Address - Country:US
Practice Address - Phone:360-676-4485
Practice Address - Fax:360-714-1294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLAHEE HOME CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YP2500X, 2084A0401X, 2084P0802X, 261QM0850X, 101Y00000X
WACO60545681251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health