Healthcare Provider Details

I. General information

NPI: 1609459916
Provider Name (Legal Business Name): GEORGE GAY CO60917266
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 W FRANKLIN ST
SHELTON WA
98584-3504
US

IV. Provider business mailing address

3609 APOLLO ST SE
LACEY WA
98503-7135
US

V. Phone/Fax

Practice location:
  • Phone: 360-763-5610
  • Fax:
Mailing address:
  • Phone: 360-522-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: