Provider Demographics
NPI:1609146745
Name:HALVORSON, MIRIAM MASON (MA 60261270)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:MASON
Last Name:HALVORSON
Suffix:
Gender:F
Credentials:MA 60261270
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3094
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-3094
Mailing Address - Country:US
Mailing Address - Phone:360-271-5344
Mailing Address - Fax:
Practice Address - Street 1:8181 OLD MILITARY RD NE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98311-9244
Practice Address - Country:US
Practice Address - Phone:360-271-5344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60261270172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker