Healthcare Provider Details

I. General information

NPI: 1578933800
Provider Name (Legal Business Name): CARRIE LEE WIMAN BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 NE OAK VIEW DR SUITE B
VANCOUVER WA
98662-6192
US

IV. Provider business mailing address

18 NE 6TH ST
BATTLE GROUND WA
98604-8521
US

V. Phone/Fax

Practice location:
  • Phone: 360-567-2211
  • Fax: 360-567-2212
Mailing address:
  • Phone: 360-921-5730
  • Fax: 360-567-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCG60359429
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: