Provider Demographics
NPI:1053746131
Name:DASTRUP, KATHY (CDP)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:DASTRUP
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 1:7511 CUSTER RD W
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499
Mailing Address - Country:US
Mailing Address - Phone:253-507-8367
Mailing Address - Fax:253-625-7613
Practice Address - Street 1:7511 CUSTER RD W
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-507-8367
Practice Address - Fax:253-625-7613
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00003652101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)