Individual
OZARK GORE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
4804 LACEY BLVD SE STE A, LACEY, WA 98503-5733
(360) 799-5782
Mailing address
6703 OAKBROOK CT SE, OLYMPIA, WA 98513-5672
(808) 214-4948
Taxonomy
Speciality
Code
Description
License number
State
103TA0400X
Addiction (Substance Use Disorder) Psychologist
Primary
—
—
Other
Enumeration date
03/06/2020
Last updated
03/06/2020
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