Provider Demographics
NPI:1780909820
Name:MACDONALD, GARY (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:MACDONALD
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 1:1175 OSAGE ST STE 201
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-3436
Mailing Address - Country:US
Mailing Address - Phone:303-573-0839
Mailing Address - Fax:
Practice Address - Street 1:1175 OSAGE ST STE 201
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-3436
Practice Address - Country:US
Practice Address - Phone:303-573-0839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3052103TB0200X
CO3052103TC1900X, 103TM1800X
CO0441416103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool