Healthcare Provider Details

I. General information

NPI: 1972262087
Provider Name (Legal Business Name): REVERIE THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 OFFICERS ROW
VANCOUVER WA
98661-3845
US

IV. Provider business mailing address

756 OFFICERS ROW
VANCOUVER WA
98661-3845
US

V. Phone/Fax

Practice location:
  • Phone: 425-477-9282
  • Fax:
Mailing address:
  • Phone: 425-477-9282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ASHLEY GRACE GUNDERSON
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LMHC
Phone: 425-477-9282