1013116193 NPI number — OLIVER BIRCHWOOD-GLOVER LCSW

Table of content: DR. JUSTINE ALYSSE GONZALEZ OD (NPI 1457889776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013116193 NPI number — OLIVER BIRCHWOOD-GLOVER LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRCHWOOD-GLOVER
Provider First Name:
OLIVER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013116193
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13 1/2 E MAIN ST
Provider Second Line Business Mailing Address:
SUITE 214
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-1950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-525-1750
Provider Business Mailing Address Fax Number:
509-525-1606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 E SUMACH ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-540-4090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW - 992649 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2010913 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".