Healthcare Provider Details

I. General information

NPI: 1467673285
Provider Name (Legal Business Name): GERRY WILWANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S 4TH AVE
YAKIMA WA
98902
US

IV. Provider business mailing address

PO BOX 959
YAKIMA WA
98907
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-4084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60131854
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: