MEDICARE: GWENDOLYN DELOACH MSW, LSWAIC

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	1041C0700X	Clinical Social Worker	61037144	WA

General Provider Information

NPI Number	:	1922766104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN DELOACH MSW, LSWAIC

Provider Business Mailing Address
First Line	:	1700 37TH AVE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-3461
Country	:	US
Telephone Number	:	917-880-9137
Fax Number	:

Provider Business Practice Location Address
First Line	:	2033 6TH AVE STE 1110
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98121-2590
Country	:	US
Telephone Number	:	206-858-1177
Fax Number	:

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

Provider Enumeration Date	:	12/03/2021
Last Update Date	:	12/03/2021

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