Provider Demographics
NPI:1083795686
Name:GERRITSEN, GREGORY W (PHD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:GERRITSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 LOVE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2975
Mailing Address - Country:US
Mailing Address - Phone:303-473-4433
Mailing Address - Fax:303-499-2217
Practice Address - Street 1:2501 WALNUT ST
Practice Address - Street 2:SUITE 202
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5751
Practice Address - Country:US
Practice Address - Phone:303-473-4433
Practice Address - Fax:303-499-2217
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07012099Medicaid
CO07012099Medicaid