Healthcare Provider Details

I. General information

NPI: 1053225904
Provider Name (Legal Business Name): GAELLE ODIA TENGU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 7TH AVE STE A
KIRKLAND WA
98033-5779
US

IV. Provider business mailing address

31211 3RD AVE SW
FEDERAL WAY WA
98023-4620
US

V. Phone/Fax

Practice location:
  • Phone: 425-658-3016
  • Fax:
Mailing address:
  • Phone: 857-832-8376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: