Provider Demographics
NPI:1457330805
Name:WEST, GERALD LEE (PHD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LEE
Last Name:WEST
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:WEST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1724 BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-9313
Mailing Address - Country:US
Mailing Address - Phone:330-833-3420
Mailing Address - Fax:330-833-8428
Practice Address - Street 1:1807 LINCOLN WAY E
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-6962
Practice Address - Country:US
Practice Address - Phone:330-833-3420
Practice Address - Fax:330-833-8428
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4566103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2052308Medicaid
OHWECP21294Medicare ID - Type UnspecifiedPROVIDER #
OH2052308Medicaid