Healthcare Provider Details

I. General information

NPI: 1194332528
Provider Name (Legal Business Name): CARRIE WEBSTER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

433 ARCHIE WAY NE
LUDOWICI GA
31316-7774
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 253-592-1470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY.60818255
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: