Healthcare Provider Details

I. General information

NPI: 1376251439
Provider Name (Legal Business Name): MARY JOY F GUMIRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15503 8TH AVE NE
SHORELINE WA
98155-6238
US

IV. Provider business mailing address

15503 8TH AVE NE
SHORELINE WA
98155-6238
US

V. Phone/Fax

Practice location:
  • Phone: 360-660-4201
  • Fax: 206-237-9222
Mailing address:
  • Phone: 360-660-4201
  • Fax: 206-237-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number755907
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: