Provider Demographics
NPI:1629698493
Name:VAN BLAIR, GRETCHEN GALLAGHER (LMHC)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:GALLAGHER
Last Name:VAN BLAIR
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:
Other - Last Name:VAN BLAIR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:816 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6419
Mailing Address - Country:US
Mailing Address - Phone:360-797-4021
Mailing Address - Fax:
Practice Address - Street 1:816 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6419
Practice Address - Country:US
Practice Address - Phone:360-797-4021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61267046101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2158459Medicaid