Provider Demographics
NPI:1013649698
Name:GWANJAYE, MICHAEL (SWIASC61316872)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GWANJAYE
Suffix:
Gender:M
Credentials:SWIASC61316872
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17018 15TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5137
Mailing Address - Country:US
Mailing Address - Phone:206-362-7286
Mailing Address - Fax:
Practice Address - Street 1:17018 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-5137
Practice Address - Country:US
Practice Address - Phone:206-362-7286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASWIA.SC.61316872101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health