Provider Demographics
NPI:1114040755
Name:CHILDHAVEN - GOGERTY BRANCH
Entity Type:Organization
Organization Name:CHILDHAVEN - GOGERTY BRANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:NINO OSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-597-4804
Mailing Address - Street 1:316 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5325
Mailing Address - Country:US
Mailing Address - Phone:206-624-6477
Mailing Address - Fax:206-382-3303
Practice Address - Street 1:1345 22ND ST NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-3442
Practice Address - Country:US
Practice Address - Phone:253-833-5908
Practice Address - Fax:253-931-8981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA19349261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health