MEDICARE: GARY R WEST MALLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	GW003290	MI

General Provider Information

NPI Number	:	1407909534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY R WEST MALLP

Provider Business Mailing Address
First Line	:	200 S WENONA ST STE 280
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-8845
Country	:	US
Telephone Number	:	989-892-4711
Fax Number	:	989-892-4761

Provider Business Practice Location Address
First Line	:	200 S WENONA ST STE 280
Second Line	:
City	:	BAY CITY
State	:	MI
Zip	:	48706-8845
Country	:	US
Telephone Number	:	989-892-4711
Fax Number	:	989-892-4761

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2007
Last Update Date	:	07/08/2007

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