Healthcare Provider Details

I. General information

NPI: 1245919877
Provider Name (Legal Business Name): GRACE EVELYN MARTIN LSWAIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 24TH AVE S STE 260
SEATTLE WA
98144-4644
US

IV. Provider business mailing address

2100 24TH AVE S STE 260
SEATTLE WA
98144-4644
US

V. Phone/Fax

Practice location:
  • Phone: 206-382-5340
  • Fax:
Mailing address:
  • Phone: 206-382-3402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61450814
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: