Provider Demographics
NPI:1962973388
Name:GUSHIKUMA, CORINE CHIEMI (MSW, MED, BCBA)
Entity type:Individual
Prefix:
First Name:CORINE
Middle Name:CHIEMI
Last Name:GUSHIKUMA
Suffix:
Gender:F
Credentials:MSW, MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3918 14TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-1428
Mailing Address - Country:US
Mailing Address - Phone:808-781-0652
Mailing Address - Fax:
Practice Address - Street 1:3111 BROAD ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-8342
Practice Address - Country:US
Practice Address - Phone:808-781-0652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WABA61033085103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician