Healthcare Provider Details

I. General information

NPI: 1891254058
Provider Name (Legal Business Name): GRETCHEN S GENDREAU PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 02/08/2024
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 N MERIDIAN
PUYALLUP WA
98371-8636
US

IV. Provider business mailing address

2205 43RD ST SE
PUYALLUP WA
98372-4280
US

V. Phone/Fax

Practice location:
  • Phone: 253-256-6594
  • Fax:
Mailing address:
  • Phone: 253-218-9912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHCA.MC.60930549
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY60968000
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY60968000
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: