Provider Demographics
NPI:1285200758
Name:GOURDINE, RICKY
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:GOURDINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3857 MARTIN WAY E
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5268
Mailing Address - Country:US
Mailing Address - Phone:360-704-7170
Mailing Address - Fax:
Practice Address - Street 1:402 YAUGER WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8660
Practice Address - Country:US
Practice Address - Phone:360-878-8248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61601654101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health