Healthcare Provider Details

I. General information

NPI: 1508201906
Provider Name (Legal Business Name): RIVER ROCK CHURCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 SE TECH CENTER PL SUITE 385
VANCOUVER WA
98683-9591
US

IV. Provider business mailing address

1498 SE TECH CENTER PL SUITE 385
VANCOUVER WA
98683-9591
US

V. Phone/Fax

Practice location:
  • Phone: 360-619-2226
  • Fax: 360-326-9691
Mailing address:
  • Phone: 360-619-2226
  • Fax: 360-326-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW60216256
License Number StateWA

VIII. Authorized Official

Name: JOSEPH MELVIN KLEMZ
Title or Position: COUNSELING DIRECTOR
Credential: LICSW
Phone: 360-619-2226