Provider Demographics
NPI:1013196716
Name:DEITCHLER, GREGORY M (MA LMFT, LPC,)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:DEITCHLER
Suffix:
Gender:M
Credentials:MA LMFT, LPC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 S. MERIDIAN RD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-350-0330
Mailing Address - Fax:208-576-6915
Practice Address - Street 1:3061 S. MERIDIAN RD.
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-350-0330
Practice Address - Fax:208-576-6915
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-949101YM0800X
IDLPC949101YP2500X
IDLMFT2935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional