Basic Information
| Provider Information | |||||||||
| NPI: | 1467501734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUTTON-GAMACHE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5837 221ST PL SE | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980278917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253910887 | ||||||||
| FaxNumber: | 4253917014 | ||||||||
| Practice Location | |||||||||
| Address1: | 5837 221ST PL SE | ||||||||
| Address2: | |||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980278917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253910887 | ||||||||
| FaxNumber: | 4253917014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 05/10/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | AA02881 | AK | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PY0001271 | WA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PS02881 | 05 | AK | MEDICAID |