Provider Demographics
NPI:1184726168
Name:KIRCHER-SAMPSON, CAROL SUE (OTR CHT)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:SUE
Last Name:KIRCHER-SAMPSON
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1953 PALISADES TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-4627
Mailing Address - Country:US
Mailing Address - Phone:503-697-8654
Mailing Address - Fax:
Practice Address - Street 1:945 11TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2555
Practice Address - Country:US
Practice Address - Phone:360-577-1192
Practice Address - Fax:360-577-0519
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00000149171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7681018Medicaid
WA06769OtherL&I
WAK14454OtherREGENCE
WA06769OtherL&I