Provider Demographics
NPI:1295961720
Name:SIPES, GWEN G (LMT, LMP)
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:G
Last Name:SIPES
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 212TH ST SW STE 205
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7617
Mailing Address - Country:US
Mailing Address - Phone:425-977-4988
Mailing Address - Fax:425-977-4989
Practice Address - Street 1:7500 212TH ST SW STE 205
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7617
Practice Address - Country:US
Practice Address - Phone:425-977-4988
Practice Address - Fax:425-977-4989
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14303225700000X
WAMA60085483225700000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty