Basic Information
Provider Information | |||||||||
NPI: | 1114177169 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ISHAM | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | CLAYTON | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CDP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17500 S SKYRIDGE DR | ||||||||
Address2: |   | ||||||||
City: | MOUNT VERNON | ||||||||
State: | WA | ||||||||
PostalCode: | 982747768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4255016257 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 17337 RESERVATION RD | ||||||||
Address2: |   | ||||||||
City: | LA CONNER | ||||||||
State: | WA | ||||||||
PostalCode: | 982578802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604661024 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2008 | ||||||||
LastUpdateDate: | 10/20/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CP00005949 | WA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 199286 | 05 | WA |   | MEDICAID |