Basic Information
Provider Information | |||||||||
NPI: | 1649517350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUERTIN | ||||||||
FirstName: | KARIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 369 | ||||||||
Address2: |   | ||||||||
City: | STEVENSON | ||||||||
State: | WA | ||||||||
PostalCode: | 98648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094273850 | ||||||||
FaxNumber: | 5094270188 | ||||||||
Practice Location | |||||||||
Address1: | 710 SW ROCK CREEK DR. | ||||||||
Address2: |   | ||||||||
City: | STEVENSON | ||||||||
State: | WA | ||||||||
PostalCode: | 983484418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094273850 | ||||||||
FaxNumber: | 5094270188 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2013 | ||||||||
LastUpdateDate: | 12/08/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | SC60504296 | WA | Y |   | Behavioral Health & Social Service Providers | Social Worker | School | 225200000X | 8020 | OR | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.