Basic Information
Provider Information | |||||||||
NPI: | 1174650808 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN GALDER | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | SC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MCGEE | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3600 LIND AVE SW | ||||||||
Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980574970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256902715 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17722 TALBOT RD S | ||||||||
Address2: |   | ||||||||
City: | RENTON | ||||||||
State: | WA | ||||||||
PostalCode: | 980555744 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4256903479 | ||||||||
FaxNumber: | 4256909479 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/28/2007 | ||||||||
LastUpdateDate: | 05/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LW60462983 | WA | Y |   | Behavioral Health & Social Service Providers | Social Worker |   |
ID Information
ID | Type | State | Issuer | Description | 2066839 | 05 | WA |   | MEDICAID |