MEDICARE: DR. GWYNNE ODETTE KOHL PHD

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	103TC0700X	Clinical Psychologist	PSYC.PY60399151	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11852	OTHER		AUTHORITY TO PRACTICE TELEPSYCHOLOGY (APIT) E. PASSPORT

General Provider Information

NPI Number	:	1356412951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWYNNE ODETTE KOHL PHD

Provider Business Mailing Address
First Line	:	6869 WOODLAWN AVE NE STE 200
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-5469
Country	:	US
Telephone Number	:	206-550-1998
Fax Number	:

Provider Business Practice Location Address
First Line	:	6869 WOODLAWN AVE NE STE 200
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98115-5469
Country	:	US
Telephone Number	:	206-550-1998
Fax Number	:

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

Provider Enumeration Date	:	11/13/2006
Last Update Date	:	10/20/2023

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