=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215123435
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH ANN CANTER LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2007
-----------------------------------------------------
Last Update Date | 09/20/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2417 BROADWAY ST
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98663-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-903-7415
-----------------------------------------------------
Fax | 360-263-3938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 923
-----------------------------------------------------
City | LA CENTER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98629-0923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-903-7415
-----------------------------------------------------
Fax | 360-263-3938
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LW00009073
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | L4029
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------