Provider Demographics
NPI:1114120144
Name:WELLIVER, RAYMOND (LICSW)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:WELLIVER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:360-428-8912
Mailing Address - Fax:
Practice Address - Street 1:1010 E COLLEGE WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5624
Practice Address - Country:US
Practice Address - Phone:360-542-8920
Practice Address - Fax:360-542-8930
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1030657101YM0800X
WALW600688461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307819Medicaid
MA1307819Medicaid
MA1307819Medicare UPIN