Provider Demographics
NPI:1922766104
Name:DELOACH, GWENDOLYN (MSW, LSWAIC)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:DELOACH
Suffix:
Gender:F
Credentials:MSW, LSWAIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3461
Mailing Address - Country:US
Mailing Address - Phone:917-880-9137
Mailing Address - Fax:
Practice Address - Street 1:2033 6TH AVE STE 1110
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-2590
Practice Address - Country:US
Practice Address - Phone:206-858-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA610371441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical