Provider Demographics
NPI:1578701900
Name:BLYCKER, GRETCHEN
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:BLYCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CAPSTAN ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835-2241
Mailing Address - Country:US
Mailing Address - Phone:401-486-7183
Mailing Address - Fax:
Practice Address - Street 1:765 ALLENS AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-5443
Practice Address - Country:US
Practice Address - Phone:401-490-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health