Provider Demographics
NPI:1962503110
Name:EUSTICE, GARY D (MS LP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:EUSTICE
Suffix:
Gender:M
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 13TH AVE E
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-3675
Mailing Address - Country:US
Mailing Address - Phone:218-263-7540
Mailing Address - Fax:
Practice Address - Street 1:302 E HOWARD ST
Practice Address - Street 2:SUITE 309
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1772
Practice Address - Country:US
Practice Address - Phone:218-966-5385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2919103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160553400Medicaid