Basic Information
| Provider Information | |||||||||
| NPI: | 1629068754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICE | ||||||||
| FirstName: | GERRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | OLSEN | ||||||||
| OtherFirstName: | GERRY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 642 DAMERON DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863012411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S CORTEZ ST | ||||||||
| Address2: | CORTEZ CLINIC | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863034319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284455211 | ||||||||
| FaxNumber: | 9287768484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC1958 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.