Provider Demographics
NPI:1447768338
Name:FARRELL, GAVIN LEE
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:LEE
Last Name:FARRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 164TH ST SE APT B302
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10575 NE 12TH ST STE 17
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4362
Practice Address - Country:US
Practice Address - Phone:425-296-3385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-13
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60767902225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist