Provider Demographics
NPI:1861150245
Name:WACHOLTZ, JOHNNA RAE
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:RAE
Last Name:WACHOLTZ
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 1:1124 W RIVERSIDE AVE # LL2
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-1132
Mailing Address - Country:US
Mailing Address - Phone:509-994-4518
Mailing Address - Fax:
Practice Address - Street 1:1124 W RIVERSIDE AVE STE LL2
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-1132
Practice Address - Country:US
Practice Address - Phone:509-994-4518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC612304251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical