Provider Demographics
NPI:1568640639
Name:UPSHAW, GERALD W
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:W
Last Name:UPSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7915
Mailing Address - Country:US
Mailing Address - Phone:253-798-4500
Mailing Address - Fax:253-798-4493
Practice Address - Street 1:3580 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7915
Practice Address - Country:US
Practice Address - Phone:253-798-4500
Practice Address - Fax:253-798-4493
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00014788101YM0800X
WANA00094615376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No376K00000XNursing Service Related ProvidersNurse's Aide