Provider Demographics
NPI:1922011253
Name:PRATER, GARY V (PSY D)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:V
Last Name:PRATER
Suffix:
Gender:M
Credentials:PSY D
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 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:3701 LANSDOWNE DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102
Practice Address - Country:US
Practice Address - Phone:606-324-3005
Practice Address - Fax:606-329-1530
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0571103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000224318OtherANTHEM BCBS
OH0871463Medicaid
001723355OtherMSBCBS
10983OtherCHA
KY7100283070Medicaid
11726241OtherCAQH
227484OtherMANAGED HEALTH
0519502Medicare PIN
001723355OtherMSBCBS
000000224318OtherANTHEM BCBS