MEDICARE: DR. WILLIAM JOHN CHALSTROM PH D

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	103T00000X	Psychologist	PY00001242	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	137334	OTHER		MANGED HEALTH NETWORK
3	37794	OTHER	WA	DEPT OF LABOR & INDUSTRIE

General Provider Information

NPI Number	:	1538255658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM JOHN CHALSTROM PH D

Provider Business Mailing Address
First Line	:	PO BOX 776
Second Line	:
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-0776
Country	:	US
Telephone Number	:	360-876-0285
Fax Number	:	360-876-4685

Provider Business Practice Location Address
First Line	:	2501 MILE HILL DRIVE
Second Line	:	SUITE A 105 PORT ORCHARD CLINICAL PSYCHOLOGY CENTER
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-0776
Country	:	US
Telephone Number	:	360-876-0285
Fax Number	:	360-876-4685

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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