Provider Demographics
NPI:1558836221
Name:GADDIS, WILLIAM BRUCE III (BA, CDC I)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:BRUCE
Last Name:GADDIS
Suffix:III
Gender:M
Credentials:BA, CDC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 1ST AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4899
Mailing Address - Country:US
Mailing Address - Phone:907-459-3800
Mailing Address - Fax:
Practice Address - Street 1:122 1ST AVE STE 600
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4899
Practice Address - Country:US
Practice Address - Phone:907-459-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1558836221Medicaid