Healthcare Provider Details

I. General information

NPI: 1205286093
Provider Name (Legal Business Name): SAMUEL OCHINANG LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-1000
US

IV. Provider business mailing address

MCDONALD ARMY HEALTH CENTER, BUILDING 576, JEFFERSON AV
FORT EUSTIS VA
23604
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-4184
  • Fax:
Mailing address:
  • Phone: 757-314-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC011573
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: