Provider Demographics
NPI:1881155273
Name:VERGEYLE, ROBERTA LYNN (LICSWA)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LYNN
Last Name:VERGEYLE
Suffix:
Gender:F
Credentials:LICSWA
Other - Prefix:
Other - First Name:BIRDIE
Other - Middle Name:LYNN
Other - Last Name:VERGEYLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSWA
Mailing Address - Street 1:92 N SALMON BCH
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2250
Mailing Address - Country:US
Mailing Address - Phone:206-387-2313
Mailing Address - Fax:
Practice Address - Street 1:401 5TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2377
Practice Address - Country:US
Practice Address - Phone:206-390-1307
Practice Address - Fax:206-296-0582
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA608812601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical