Basic Information
| Provider Information | |||||||||
| NPI: | 1356606537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VON WALTHER | ||||||||
| FirstName: | KONRAD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WALTHER | ||||||||
| OtherFirstName: | KONRAD | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD | ||||||||
| Address2: | SUITE 367 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037425300 | ||||||||
| FaxNumber: | 5037425979 | ||||||||
| Practice Location | |||||||||
| Address1: | 38872 PROCTOR BLVD | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970558035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037226950 | ||||||||
| FaxNumber: | 5037226939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2012 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.