=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407951742
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER SAM WERKHOVEN MSW, LICSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | VA PUGET SOUND HEALTH CARE SYSTEM A 112 VIST 9600 VETERANS DRIVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98393-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-583-1287
-----------------------------------------------------
Fax | 253-589-4125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10111 89TH AVE E
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98373-1386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-583-1287
-----------------------------------------------------
Fax | 253-589-4125
-----------------------------------------------------
=====================================================
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 | LW00004860
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------