Provider Demographics
NPI:1891241568
Name:LIVE WELL ALLIANCE, LLC
Entity Type:Organization
Organization Name:LIVE WELL ALLIANCE, LLC
Other - Org Name:GINA G GROUP GINA GUDDAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNSELOR, DIRECTOR OF GROUP PRACTI
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GUDDAT
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:888-232-0222
Mailing Address - Street 1:P.O. BOX 9572
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109
Mailing Address - Country:US
Mailing Address - Phone:888-232-0222
Mailing Address - Fax:
Practice Address - Street 1:1103 W. MEEKER STREET #102
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032
Practice Address - Country:US
Practice Address - Phone:888-232-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60217335101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty