Provider Demographics
NPI:1972625796
Name:BISCHOF, GARY H (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:H
Last Name:BISCHOF
Suffix:
Gender:M
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6346 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2308
Mailing Address - Country:US
Mailing Address - Phone:269-321-0270
Mailing Address - Fax:269-387-5090
Practice Address - Street 1:724 W CENTRE AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-6310
Practice Address - Country:US
Practice Address - Phone:269-569-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006184106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4101006184OtherLIC MFT