Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 5052 | ND |
NPI | 1003217795 |
---|---|
Provider Name | Taylor Carlstrom |
First Address | Mcminnville, OR 97128-3923 |
Second Address | Mcminnville, OR 97128-3923 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2014 |
Last Update Date | 28/11/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
74257 | (05) | ND |