MEDICARE: GINA MARIE FUDACZ

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1780336107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA MARIE FUDACZ

Provider Business Mailing Address
First Line	:	1902 2ND AVE
Second Line	:	C/O CREW
City	:	SEATTLE
State	:	WA
Zip	:	98101-1155
Country	:	US
Telephone Number	:	206-956-9570
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 BELL ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98121-1748
Country	:	US
Telephone Number	:	206-456-3456
Fax Number	:	206-456-3487

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

Provider Enumeration Date	:	01/26/2022
Last Update Date	:	01/26/2022

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