Provider Demographics
NPI:1417170119
Name:EHRICH, GARY P (CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:P
Last Name:EHRICH
Suffix:
Gender:M
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 ASH ST STE OS2O
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1201
Mailing Address - Country:US
Mailing Address - Phone:715-939-1248
Mailing Address - Fax:715-939-1248
Practice Address - Street 1:100 POLK COUNTY PLZ STE 50
Practice Address - Street 2:
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-9097
Practice Address - Country:US
Practice Address - Phone:715-485-8879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11506 135101YA0400X
WI1819 132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39355100Medicaid
WI256704OtherMHN HMC INSURANCE
WI1044866OtherPREFERREDONE INS