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General NPI Number Information
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NPI Number | 1477259927
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Entity Type | Individual
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Provider Name | WALTER WILLIAM COBURN I
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Gender | Male
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Dates
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Enumeration Date | 02/06/2023
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 1960 THOMPSON DR
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City | SEDRO WOOLLEY
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State | WA
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Zip | 98284-5007
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Country | US
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Telephone | 360-856-3186
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Fax |
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Provider Business Mailing Address
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Address Line | 1203 E SECTION ST
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City | MOUNT VERNON
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State | WA
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Zip | 98274-5020
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Country | US
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Telephone | 253-227-1844
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LP60342552
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | LP60342552
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License Number State | WA
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