Provider Demographics
NPI:1396909917
Name:GRESICK, ED W (MS)
Entity type:Individual
Prefix:
First Name:ED
Middle Name:W
Last Name:GRESICK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 FAIR AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-5828
Mailing Address - Country:US
Mailing Address - Phone:831-427-1007
Mailing Address - Fax:
Practice Address - Street 1:707 FAIR AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-5828
Practice Address - Country:US
Practice Address - Phone:831-427-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-13
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN6420450OtherDRIVER LICENSE NUMBER