Provider Demographics
NPI:1518175025
Name:MYDLAND, J. GABRIEL (EDD LPC)
Entity Type:Individual
Prefix:DR
First Name:J. GABRIEL
Middle Name:
Last Name:MYDLAND
Suffix:
Gender:M
Credentials:EDD LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 22ND AVE S PMB 179
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006
Mailing Address - Country:US
Mailing Address - Phone:605-691-0463
Mailing Address - Fax:
Practice Address - Street 1:928 4TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2171
Practice Address - Country:US
Practice Address - Phone:605-691-0463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1057101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health