=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417170119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY P EHRICH CSAC, ICS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 09/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 POLK COUNTY PLZ STE 50
-----------------------------------------------------
City | BALSAM LAKE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54810-9097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-485-8879
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 819 ASH ST STE OS2O
-----------------------------------------------------
City | SPOONER
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54801-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-939-1248
-----------------------------------------------------
Fax | 715-939-1248
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 11506 135
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1819 132
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------