Provider Demographics
NPI:1659331262
Name:PERCIVAL, GARY L (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:PERCIVAL
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 1:11123 E 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5518
Mailing Address - Country:US
Mailing Address - Phone:509-891-7713
Mailing Address - Fax:
Practice Address - Street 1:800 W SURVIVAL LOOP
Practice Address - Street 2:BUILDING 1255
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8680
Practice Address - Country:US
Practice Address - Phone:509-247-9714
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT317398-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist