Provider Demographics
NPI:1538641766
Name:MCGIVENEY, EDWARD JAMES JR
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JAMES
Last Name:MCGIVENEY
Suffix:JR
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 1:1014 BAY ST STE 24
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5244
Mailing Address - Country:US
Mailing Address - Phone:360-602-0022
Mailing Address - Fax:360-335-6432
Practice Address - Street 1:1014 BAY ST STE 24
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5244
Practice Address - Country:US
Practice Address - Phone:360-602-0022
Practice Address - Fax:360-335-6432
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60748950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)