1538255658 NPI number — DR. WILLIAM JOHN CHALSTROM PH D

Table of content: DR. WILLIAM JOHN CHALSTROM PH D (NPI 1538255658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538255658 NPI number — DR. WILLIAM JOHN CHALSTROM PH D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHALSTROM
Provider First Name:
WILLIAM
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH D
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:
1538255658
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:
PO BOX 776
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-0776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-876-0285
Provider Business Mailing Address Fax Number:
360-876-4685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2501 MILE HILL DRIVE
Provider Second Line Business Practice Location Address:
SUITE A 105 PORT ORCHARD CLINICAL PSYCHOLOGY CENTER
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-0776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-876-0285
Provider Business Practice Location Address Fax Number:
360-876-4685
Provider Enumeration Date:
10/05/2006

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: 103T00000X , with the licence number:  PY00001242 , 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)

  • Identifier: 7046725 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 137334 . This is a "MANGED HEALTH NETWORK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37794 . This is a "DEPT OF LABOR & INDUSTRIE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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