Provider Demographics
NPI:1780172494
Name:GASTINEAU, PHILIP (LPC)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:GASTINEAU
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6604 BLUE MIST RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46819-1502
Mailing Address - Country:US
Mailing Address - Phone:260-705-9347
Mailing Address - Fax:
Practice Address - Street 1:1836 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8901
Practice Address - Country:US
Practice Address - Phone:616-457-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000602A101YM0800X
MI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty