Healthcare Provider Details

I. General information

NPI: 1184741282
Provider Name (Legal Business Name): GREGORY W. MONDIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W STATE ST
BOISE ID
83702-6052
US

IV. Provider business mailing address

220 W STATE ST
BOISE ID
83702-6052
US

V. Phone/Fax

Practice location:
  • Phone: 208-331-2822
  • Fax: 208-345-1947
Mailing address:
  • Phone: 208-331-2822
  • Fax: 208-345-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY392
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: