Healthcare Provider Details

I. General information

NPI: 1285465591
Provider Name (Legal Business Name): MARK SCOTT GERRY II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26731 W POINT MACKENZIE RD
WASILLA AK
99623-8709
US

IV. Provider business mailing address

PO BOX 871545
WASILLA AK
99687-1545
US

V. Phone/Fax

Practice location:
  • Phone: 907-376-4534
  • Fax: 907-376-2348
Mailing address:
  • Phone: 907-376-4534
  • Fax: 907-376-2348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5183
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: