Provider Demographics
NPI:1710970462
Name:GURGEL, CARRIE (MED)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:
Last Name:GURGEL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2145
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-1465
Mailing Address - Country:US
Mailing Address - Phone:208-743-4680
Mailing Address - Fax:208-743-1756
Practice Address - Street 1:422 17TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2526
Practice Address - Country:US
Practice Address - Phone:208-743-4680
Practice Address - Fax:208-743-1756
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC836101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010016553OtherBLUESHIELD OF IDAHO
IDX0359OtherBLUE CROSS OF IDAHO