Provider Demographics
NPI:1932533106
Name:BANCHERO, GWENDOLYN KAYE (LMP)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:KAYE
Last Name:BANCHERO
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15600 NE 8TH ST STE B1
Mailing Address - Street 2:313
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-3958
Mailing Address - Country:US
Mailing Address - Phone:206-999-9290
Mailing Address - Fax:
Practice Address - Street 1:1411 150TH AVE SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-5812
Practice Address - Country:US
Practice Address - Phone:206-999-9290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60367962225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist