Provider Demographics
NPI:1114355757
Name:PETERSON, GAIL INGRA (MS, LCPC)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:INGRA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 11TH AVE S STE 204
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5074
Mailing Address - Country:US
Mailing Address - Phone:208-871-7040
Mailing Address - Fax:208-908-6164
Practice Address - Street 1:320 11TH AVE S STE 204
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-5074
Practice Address - Country:US
Practice Address - Phone:208-871-7040
Practice Address - Fax:208-908-6164
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-6750101YM0800X
IDLPC-5336101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health