Healthcare Provider Details

I. General information

NPI: 1760450589
Provider Name (Legal Business Name): LYNN S. GILDERHUS LMFT & LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

10240 BRIDGEPORT WAY SW #210
LAKEWOOD WA
98499-2304
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-2764
  • Fax:
Mailing address:
  • Phone: 253-202-2137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60178159
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF60160552
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: