Healthcare Provider Details

I. General information

NPI: 1972674521
Provider Name (Legal Business Name): MR. GARY DON YEAST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E KENT STREET
WAUSAU WI
54403
US

IV. Provider business mailing address

PO BOX 615
WAUSAU WI
54402-0615
US

V. Phone/Fax

Practice location:
  • Phone: 715-842-3913
  • Fax: 715-842-0092
Mailing address:
  • Phone: 715-842-3913
  • Fax: 715-842-0092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number148124MFT
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: