Provider Demographics
NPI:1114593886
Name:WHALEN, DOUGLAS MARK (LICSW)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MARK
Last Name:WHALEN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22620 SE 4TH ST STE 130
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-7375
Mailing Address - Country:US
Mailing Address - Phone:855-402-1364
Mailing Address - Fax:425-974-7861
Practice Address - Street 1:22620 SE 4TH ST STE 130
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98074-7375
Practice Address - Country:US
Practice Address - Phone:855-402-1364
Practice Address - Fax:425-974-7861
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW616570341041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2178499Medicaid