Provider Demographics
NPI:1174660690
Name:DICK, GWENDOLYN (LMP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:DICK
Suffix:
Gender:F
Credentials:LMP
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 494
Mailing Address - Street 2:
Mailing Address - City:PATEROS
Mailing Address - State:WA
Mailing Address - Zip Code:98846-0494
Mailing Address - Country:US
Mailing Address - Phone:509-421-0106
Mailing Address - Fax:
Practice Address - Street 1:526 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:WA
Practice Address - Zip Code:98812
Practice Address - Country:US
Practice Address - Phone:509-421-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020348225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist