Healthcare Provider Details

I. General information

NPI: 1609456003
Provider Name (Legal Business Name): ANDREA J EWALT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5410 N 44TH ST
TACOMA WA
98407-3799
US

IV. Provider business mailing address

1305 TACOMA AVE S
TACOMA WA
98402-1903
US

V. Phone/Fax

Practice location:
  • Phone: 253-759-9544
  • Fax:
Mailing address:
  • Phone: 480-737-4736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: