=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508201906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER ROCK CHURCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2013
-----------------------------------------------------
Last Update Date | 04/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1498 SE TECH CENTER PL SUITE 385
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-9591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-619-2226
-----------------------------------------------------
Fax | 360-326-9691
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1498 SE TECH CENTER PL SUITE 385
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683-9591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-619-2226
-----------------------------------------------------
Fax | 360-326-9691
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELING DIRECTOR
-----------------------------------------------------
Name | JOSEPH MELVIN KLEMZ
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 360-619-2226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LW60216256
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------