Provider Demographics
NPI:1962559054
Name:WASHINGTON STATE UNIVERSITY
Entity type:Organization
Organization Name:WASHINGTON STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR AND CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CHERMAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC-A
Authorized Official - Phone:509-335-4526
Mailing Address - Street 1:DAGGY HALL, ROOM 133
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99164-2420
Mailing Address - Country:US
Mailing Address - Phone:509-335-1509
Mailing Address - Fax:509-335-8357
Practice Address - Street 1:DAGGY HALL, ROOM 133
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99164-2420
Practice Address - Country:US
Practice Address - Phone:509-335-1509
Practice Address - Fax:509-335-8357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WASHINGTON STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-04
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003762231HA2500X
WA00549253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000010156099OtherSPEECHLANGUAGEHEARING
WA7118771Medicaid
WA17209OtherSPEECHLANGUAGEHEARING
WA7259302Medicaid
ID805173000Medicaid
ID000010156099OtherSPEECHLANGUAGEHEARING
WA224297224297OtherSPEECHLANGUAGEHEARING
WA75243OtherSPEECHLANGUAGEHEARING
WA224297224297OtherSPEECHLANGUAGEHEARING