Basic Information
| Provider Information | |||||||||
| NPI: | 1053422014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAHLKE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 945 11TH AVE | ||||||||
| Address2: | #B | ||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604148600 | ||||||||
| FaxNumber: | 3606367372 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 11TH AVE | ||||||||
| Address2: | #B | ||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604148600 | ||||||||
| FaxNumber: | 3606367372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 11/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY1687 | WA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 8921392 | 01 | WA | CRIME VICTIMS | OTHER | 98632A009 | 01 | WA | TRECARE | OTHER |