Provider Demographics
NPI:1346428133
Name:PRATT, GINA RENEE (MS)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:RENEE
Last Name:PRATT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:RENEE
Other - Last Name:DEXTER-PRATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:411 N. ALLUMBAUGH ST.
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-338-4699
Mailing Address - Fax:
Practice Address - Street 1:411 ALLUMBAUGH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9210
Practice Address - Country:US
Practice Address - Phone:208-338-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-3115101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional