MEDICARE: MRS. CARLA SUE CHASE SOCIAL WORKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW00006013	WA

General Provider Information

NPI Number	:	1124093364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLA SUE CHASE SOCIAL WORKER

Provider Business Mailing Address
First Line	:	40717 5TH AVE. S.
Second Line	:
City	:	ROY
State	:	WA
Zip	:	98580-0000
Country	:	US
Telephone Number	:	253-968-4193
Fax Number	:	253-968-4249

Provider Business Practice Location Address
First Line	:	40717 5TH AVENUE SOUTH
Second Line	:
City	:	ROY
State	:	WA
Zip	:	98580-0000
Country	:	US
Telephone Number	:	253-968-4193
Fax Number	:	253-968-4249

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	07/08/2007

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