Healthcare Provider Details

I. General information

NPI: 1508217290
Provider Name (Legal Business Name): PHILIP CHARLES LOHMAN IV LSWAIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 E MAIN ST STE 600
OTHELLO WA
99344-1146
US

IV. Provider business mailing address

425 E MAIN ST STE 600
OTHELLO WA
99344-1146
US

V. Phone/Fax

Practice location:
  • Phone: 509-488-4074
  • Fax: 509-488-0166
Mailing address:
  • Phone: 509-488-4074
  • Fax: 509-488-0166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSWIA.SC.60941265
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWIA.SC.60941265
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: