Provider Demographics
NPI:1013297621
Name:GERRISH, WINSLOW GREGORY (PHD)
Entity Type:Individual
Prefix:DR
First Name:WINSLOW
Middle Name:GREGORY
Last Name:GERRISH
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 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-202684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1013297621Medicaid
ID20002915Medicare PIN
ID20002919Medicare PIN
ID20002916Medicare PIN
ID1013297621Medicaid
ID20002918Medicare PIN