Provider Demographics
NPI:1538255658
Name:CHALSTROM, WILLIAM JOHN (PH D)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOHN
Last Name:CHALSTROM
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-0776
Mailing Address - Country:US
Mailing Address - Phone:360-876-0285
Mailing Address - Fax:360-876-4685
Practice Address - Street 1:2501 MILE HILL DRIVE
Practice Address - Street 2:SUITE A 105 PORT ORCHARD CLINICAL PSYCHOLOGY CENTER
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-0776
Practice Address - Country:US
Practice Address - Phone:360-876-0285
Practice Address - Fax:360-876-4685
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001242103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7046725Medicaid
137334OtherMANGED HEALTH NETWORK
WA37794OtherDEPT OF LABOR & INDUSTRIE