Provider Demographics
NPI:1952495228
Name:STANTON, GARY LOUIS (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LOUIS
Last Name:STANTON
Suffix:
Gender:M
Credentials:PHD
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 1356
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1356
Mailing Address - Country:US
Mailing Address - Phone:208-765-0955
Mailing Address - Fax:208-765-6972
Practice Address - Street 1:1115 IRONWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4936
Practice Address - Country:US
Practice Address - Phone:208-765-0955
Practice Address - Fax:208-765-6972
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY376103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDX3924OtherBLUE CROSS
000010016544OtherBLUE SHIELD