Healthcare Provider Details

I. General information

NPI: 1932333960
Provider Name (Legal Business Name): GINA LYNN GUDDAT B.A. M.A. - PSCYHOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12345 ROOSEVELT WAY NE
SEATTLE WA
98125
US

IV. Provider business mailing address

12345 ROOSEVELT WAY NE
SEATTLE WA
98125
US

V. Phone/Fax

Practice location:
  • Phone: 888-232-0222
  • Fax:
Mailing address:
  • Phone: 888-232-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberRC60062663
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMC60142709
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: