Provider Demographics
NPI:1548773997
Name:VAN DAM, CARLA (PHD)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:VAN DAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 4453
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-0453
Mailing Address - Country:US
Mailing Address - Phone:360-956-0271
Mailing Address - Fax:
Practice Address - Street 1:2620 RW JOHNSON BLVD SW SUITE 204
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501
Practice Address - Country:US
Practice Address - Phone:360-956-0271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002218103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0364237OtherLABOR AND INDUSTRIES