1407951742 NPI number — MR. WALTER SAM WERKHOVEN MSW, LICSW

Table of content: MR. WALTER SAM WERKHOVEN MSW, LICSW (NPI 1407951742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407951742 NPI number — MR. WALTER SAM WERKHOVEN MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WERKHOVEN
Provider First Name:
WALTER
Provider Middle Name:
SAM
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
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:
1407951742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10111 89TH AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98373-1386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-583-1287
Provider Business Mailing Address Fax Number:
253-589-4125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VA PUGET SOUND HEALTH CARE SYSTEM A 112 VIST
Provider Second Line Business Practice Location Address:
9600 VETERANS DRIVE
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98393-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-583-1287
Provider Business Practice Location Address Fax Number:
253-589-4125
Provider Enumeration Date:
09/13/2006

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: 1041C0700X , with the licence number:  LW00004860 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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