Healthcare Provider Details

I. General information

NPI: 1811804313
Provider Name (Legal Business Name): THEODORE JAMES GUTTERUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27203 216TH AVE SE STE 5
MAPLE VALLEY WA
98038-3273
US

IV. Provider business mailing address

22870 SE FIR ST APT A301
BLACK DIAMOND WA
98010-5142
US

V. Phone/Fax

Practice location:
  • Phone: 425-243-2094
  • Fax:
Mailing address:
  • Phone: 206-886-5323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: