Provider Demographics
NPI:1558792929
Name:GILDYARD, DESEAN
Entity Type:Individual
Prefix:
First Name:DESEAN
Middle Name:
Last Name:GILDYARD
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 1:1019 S OXFORD ST STE 901
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98465-1831
Mailing Address - Country:US
Mailing Address - Phone:206-817-7947
Mailing Address - Fax:
Practice Address - Street 1:26612 111TH PL SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-9033
Practice Address - Country:US
Practice Address - Phone:206-817-7947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health