Healthcare Provider Details

I. General information

NPI: 1649938168
Provider Name (Legal Business Name): GRETCHEN H VAN BODEGOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 S COWLEY ST STE 9
SPOKANE WA
99202-1263
US

IV. Provider business mailing address

922 S COWLEY ST STE 9
SPOKANE WA
99202-1263
US

V. Phone/Fax

Practice location:
  • Phone: 509-822-6777
  • Fax: 509-676-6655
Mailing address:
  • Phone: 509-822-6777
  • Fax: 509-676-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61551656
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: