Basic Information
| Provider Information | |||||||||
| NPI: | 1699428953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERMIRE | ||||||||
| FirstName: | YAJAIRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | SUDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1313 N 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993628817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1313 N 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993628817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095253610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2022 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO61145287 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2077844 | 05 | WA | MEDICAID |