1295028421 NPI number — CAROLYN LYNN VANDERBLOEMEN MSW

Table of content: CAROLYN LYNN VANDERBLOEMEN MSW (NPI 1295028421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295028421 NPI number — CAROLYN LYNN VANDERBLOEMEN MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERBLOEMEN
Provider First Name:
CAROLYN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURKE
Provider Other First Name:
CAROLYN
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295028421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 FIRLAND DR
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:
98371-6623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-298-9808
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 14TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-697-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2011

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:  C003293 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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