Provider Demographics
NPI:1750803383
Name:MOORE, KATREACE KATRELL (CDP)
Entity type:Individual
Prefix:
First Name:KATREACE
Middle Name:KATRELL
Last Name:MOORE
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:KATREACE
Other - Middle Name:KATRELL
Other - Last Name:SUMRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDP
Mailing Address - Street 1:200 LILLY RD NE STE C
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5080
Mailing Address - Country:US
Mailing Address - Phone:360-943-8810
Mailing Address - Fax:360-943-0931
Practice Address - Street 1:325 E PIONEER
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3265
Practice Address - Country:US
Practice Address - Phone:253-697-8400
Practice Address - Fax:253-697-3730
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00006362101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)