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NPI Code Detail

MEDICARE: MATTHEW D GANDALL

MEDICARE: MATTHEW D GANDALL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YM0800XMental Health CounselorRC00040924WA

General Provider Information

NPI Number : 1396881462
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW D GANDALL
Provider Business Mailing Address
First Line : 11802 4TH AVE W
Second Line : APT A-101
City : EVERETT
State : WA
Zip : 98204-4949
Country : US
Telephone Number : 425-771-5166
Fax Number : 425-670-2807
Provider Business Practice Location Address
First Line : 547 DAYTON ST
Second Line :
City : EDMONDS
State : WA
Zip : 98020-3431
Country : US
Telephone Number : 425-771-5166
Fax Number : 425-670-2807
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/29/2007
Last Update Date : 07/08/2007

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Directions to “ MATTHEW D GANDALL ” Practice Location

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