Provider Demographics
NPI:1114499324
Name:WALTER, TASHA ANNE (CADC 1, CRM, PSS)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:ANNE
Last Name:WALTER
Suffix:
Gender:F
Credentials:CADC 1, CRM, PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3416
Mailing Address - Country:US
Mailing Address - Phone:541-756-3111
Mailing Address - Fax:541-756-2111
Practice Address - Street 1:155 S EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-3374
Practice Address - Country:US
Practice Address - Phone:541-756-3111
Practice Address - Fax:541-756-2111
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHA-I-00761101YM0800X
OR11-CRM-131175T00000X
ORTHW000002674175T00000X
OR12-12-62101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist