Provider Demographics
NPI:1407909534
Name:WEST, GARY R (MALLP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:WEST
Suffix:
Gender:M
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WENONA ST STE 280
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8845
Mailing Address - Country:US
Mailing Address - Phone:989-892-4711
Mailing Address - Fax:989-892-4761
Practice Address - Street 1:200 S WENONA ST STE 280
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-8845
Practice Address - Country:US
Practice Address - Phone:989-892-4711
Practice Address - Fax:989-892-4761
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGW003290103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical