Provider Demographics
NPI:1417229626
Name:RETALLICK, R GARTH (MS, LMHC)
Entity type:Individual
Prefix:
First Name:R
Middle Name:GARTH
Last Name:RETALLICK
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SIDNEY PKWY UNIT 14
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-5318
Mailing Address - Country:US
Mailing Address - Phone:360-471-4398
Mailing Address - Fax:
Practice Address - Street 1:707 SIDNEY PKWY UNIT 14
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5318
Practice Address - Country:US
Practice Address - Phone:360-471-4398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
WALH 60344426101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor