Individual
MR. GARY CLAYTON ISHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CDP
Contact information
Practice address
17337 RESERVATION RD, LA CONNER, WA 98257-8802
(360) 466-1024
Mailing address
17500 S SKYRIDGE DR, MOUNT VERNON, WA 98274-7768
(425) 501-6257
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
CP00005949
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
199286
—
WA
Enumeration date
09/26/2008
Last updated
10/20/2014
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