Doctor Name: | GARY IVERSON |
NPI Number: | 1083086599 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | |
Business Practice Address: | 3018 Old Minden Rd Ste 1117 Bossier City, LA - 711122497 |
Business Phone Number: | 3187461935 |
Business Fax Number: | |
Mailing Address: | 3018 Old Minden Rd Ste 1117, BOSSIER CITY |
State: | LA |
Postal Code: | 711122497 |
Phone Number: | 3187461935 |
Fax Number: | |
NPI Enumeration Date: | 10/23/2015 |
NPI Last Update Date: | 10/23/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |