Provider Demographics
NPI:1174650808
Name:VAN GALDER, AMY MARIE (SC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:VAN GALDER
Suffix:
Gender:F
Credentials:SC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:MCGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:17722 TALBOT RD S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5744
Practice Address - Country:US
Practice Address - Phone:425-690-3479
Practice Address - Fax:425-690-9479
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60462983104100000X
104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2066839Medicaid
WA2066839Medicaid