| Doctor Name: | MR. GARY CLAYTON ISHAM |
| NPI Number: | 1114177169 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CDP |
| License Number: | CP00005949 |
| Business Practice Address: | 17337 Reservation Rd La Conner, WA - 982578802 |
| Business Phone Number: | 3604661024 |
| Business Fax Number: | |
| Mailing Address: | 17500 S Skyridge Dr, MOUNT VERNON |
| State: | WA |
| Postal Code: | 982747768 |
| Phone Number: | 4255016257 |
| Fax Number: | |
| NPI Enumeration Date: | 09/26/2008 |
| NPI Last Update Date: | 10/20/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | CP00005949 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |