Provider Demographics
NPI:1083829055
Name:CIVISH, GAYLE ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:ANN
Last Name:CIVISH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 CONEFLOWER CT
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-6012
Mailing Address - Country:US
Mailing Address - Phone:303-443-9570
Mailing Address - Fax:
Practice Address - Street 1:10200 W 44TH AVE
Practice Address - Street 2:SUITE 210-B
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2837
Practice Address - Country:US
Practice Address - Phone:303-443-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1170103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist