1114911922 NPI number — GAYLE M TATE-CASSON LICSW

Table of content: GAYLE M TATE-CASSON LICSW (NPI 1114911922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114911922 NPI number — GAYLE M TATE-CASSON LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TATE-CASSON
Provider First Name:
GAYLE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TATE
Provider Other First Name:
GAYLE
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1114911922
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-7154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-414-2048
Provider Business Mailing Address Fax Number:
360-414-2054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-414-2222
Provider Business Practice Location Address Fax Number:
360-414-2220
Provider Enumeration Date:
09/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LW00006409 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LW00006409 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8923628 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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