Provider Demographics
NPI:1598479776
Name:GEROSIN, LUKE
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:GEROSIN
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 1:4090 N AMBERCREEK AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7021
Mailing Address - Country:US
Mailing Address - Phone:208-761-4305
Mailing Address - Fax:
Practice Address - Street 1:921 S ORCHARD ST STE G
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1992
Practice Address - Country:US
Practice Address - Phone:888-392-8642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician