Provider Demographics
NPI:1609201532
Name:GIMMESON, BRYAN LEON (LPC)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:LEON
Last Name:GIMMESON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 LEWISTON ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:ID
Mailing Address - Zip Code:83522-5071
Mailing Address - Country:US
Mailing Address - Phone:208-962-7217
Mailing Address - Fax:
Practice Address - Street 1:236 RADAR RD
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-5165
Practice Address - Country:US
Practice Address - Phone:208-962-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional