Provider Demographics
NPI:1376563791
Name:FOX, GARY P (LPCC, LADC, SAP, MAC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:FOX
Suffix:
Gender:M
Credentials:LPCC, LADC, SAP, MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 MAIN ST STE 510
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-0710
Mailing Address - Country:US
Mailing Address - Phone:507-458-5340
Mailing Address - Fax:
Practice Address - Street 1:319 MAIN ST STE 510
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-0710
Practice Address - Country:US
Practice Address - Phone:507-458-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4630-125101YP2500X
MN460101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA179934553AMedicaid