Basic Information
| Provider Information | |||||||||
| NPI: | 1962503110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EUSTICE | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MS LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3920 13TH AVE E | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557463675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182637540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 302 E HOWARD ST | ||||||||
| Address2: | SUITE 309 | ||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557461772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189665385 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP2919 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 160553400 | 05 | MN | MEDICAID |