Provider Demographics
NPI:1265028773
Name:LISLE, GWENDOLYN DACUP
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:DACUP
Last Name:LISLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:ENGRACIA
Other - Last Name:DACUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:498 POINT BROWN AVE NE
Mailing Address - Street 2:
Mailing Address - City:OCEAN SHORES
Mailing Address - State:WA
Mailing Address - Zip Code:98569-9348
Mailing Address - Country:US
Mailing Address - Phone:360-743-0559
Mailing Address - Fax:
Practice Address - Street 1:8282 28TH CT NE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-7162
Practice Address - Country:US
Practice Address - Phone:360-915-6868
Practice Address - Fax:360-515-5783
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician