1609628775 NPI number — SUZANNE REBECCA GERLACH BS PSYCH

Table of content: AMANDA WILKIE LMT (NPI 1861262750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609628775 NPI number — SUZANNE REBECCA GERLACH BS PSYCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GERLACH
Provider First Name:
SUZANNE
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BS PSYCH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609628775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1227 E MAINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83686-7278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-900-8240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6205 W OVERLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83709-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-900-8240
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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