Provider Demographics
NPI:1063880474
Name:GAUTREAU, DANIEL THOMAS (PSYD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
Last Name:GAUTREAU
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10333 19TH AVE SE STE 109
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4267
Mailing Address - Country:US
Mailing Address - Phone:425-742-4600
Mailing Address - Fax:425-225-6859
Practice Address - Street 1:10333 19TH AVE SE STE 109
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4267
Practice Address - Country:US
Practice Address - Phone:425-742-4600
Practice Address - Fax:425-225-6859
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60971095103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6758Medicaid
CA7420Medicaid
CA7068Medicaid