Provider Demographics
NPI:1528394970
Name:POLHAMUS, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:POLHAMUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 E MAIN
Mailing Address - Street 2:SUITE 450
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6779
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 E MAIN
Practice Address - Street 2:SUITE 450
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6779
Practice Address - Country:US
Practice Address - Phone:253-604-4354
Practice Address - Fax:253-604-4732
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health