MEDICARE: GREGORY WAYNE THEURER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	PY00001822	WA

General Provider Information

NPI Number	:	1174685275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY WAYNE THEURER PH.D.

Provider Business Mailing Address
First Line	:	6715 GREENWOOD AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-5225
Country	:	US
Telephone Number	:	204-718-6869
Fax Number	:

Provider Business Practice Location Address
First Line	:	6715 GREENWOOD AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-5225
Country	:	US
Telephone Number	:	204-718-6869
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/08/2007

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