Provider Demographics
NPI:1467572974
Name:GINGERICH, COLLEEN M (LPC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:GINGERICH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47589 STATE HIGHWAY 78
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-5081
Mailing Address - Country:US
Mailing Address - Phone:208-845-2868
Mailing Address - Fax:
Practice Address - Street 1:47589 STATE HIGHWAY 78
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-5081
Practice Address - Country:US
Practice Address - Phone:208-845-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3380101YM0800X
IDLSW-610104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLPC-3380OtherLICENSED PROFESSIONAL COU
IDLSW-610OtherLICENSED SOCIAL WORKER