Provider Demographics
NPI:1821418633
Name:GERENA, ISMAEL EDGE JR (MA, LMHCA, LMFTA)
Entity Type:Individual
Prefix:MR
First Name:ISMAEL
Middle Name:EDGE
Last Name:GERENA
Suffix:JR
Gender:M
Credentials:MA, LMHCA, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BOREN AVE
Mailing Address - Street 2:SUITE 1015
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3595
Mailing Address - Country:US
Mailing Address - Phone:425-591-2963
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE
Practice Address - Street 2:SUITE 1015
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3595
Practice Address - Country:US
Practice Address - Phone:206-801-3555
Practice Address - Fax:206-801-3264
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60449151101YM0800X
WAMG60449387106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist