Basic Information
| Provider Information | |||||||||
| NPI: | 1184963902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAICELY | ||||||||
| FirstName: | TAKIYA | ||||||||
| MiddleName: | KAJUAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW, DCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARDNER | ||||||||
| OtherFirstName: | TAKIYA | ||||||||
| OtherMiddleName: | KAJUAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 107 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | 5093632762 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 E 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | 5093632762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2013 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34006655A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 390200000X | CG60965821 | WA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.