Provider Demographics
NPI:1114911922
Name:TATE-CASSON, GAYLE M (LICSW)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:M
Last Name:TATE-CASSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:GAYLE
Other - Middle Name:M
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-7154
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-414-2054
Practice Address - Street 1:600 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3256
Practice Address - Country:US
Practice Address - Phone:360-414-2222
Practice Address - Fax:360-414-2220
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW00006409104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8923628OtherCRIME VICTIMS
AB13972Medicare ID - Type Unspecified
WAAB26591Medicare ID - Type UnspecifiedPIN NUMBER - PHBH
WA8923628OtherCRIME VICTIMS