Basic Information
| Provider Information | |||||||||
| NPI: | 1194076497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOYER | ||||||||
| FirstName: | MELODY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LICSW, QCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROHWEDDER | ||||||||
| OtherFirstName: | MELODY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | R3742 RAILROAD AVE (1-2 EBH) | ||||||||
| City: | JBLM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539663627 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | JOINT BASE LEWIS MCCHORD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
| FaxNumber: | 2539683278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2012 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 1634 | NE | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 1590 | NE | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.