Provider Demographics
NPI:1821413113
Name:VAIL, GRETCHEN (MA)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:VAIL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 K ST
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-4107
Mailing Address - Country:US
Mailing Address - Phone:707-464-7224
Mailing Address - Fax:
Practice Address - Street 1:455 K ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4107
Practice Address - Country:US
Practice Address - Phone:707-464-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94-2254126101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-2254126Medicaid