Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | LW00005964 | WA |
NPI | 1003205147 |
---|---|
Provider Name | Mr. C Henry Balderrama |
First Address | Federal Way, WA 98023-7029 |
Second Address | Tacoma, WA 98405-2047 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/01/2015 |
Last Update Date | 10/09/2015 |