Provider Demographics
NPI:1174702385
Name:WATERHOUSE, GLORIA JENNINGS (PHD)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:JENNINGS
Last Name:WATERHOUSE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1376
Mailing Address - Country:US
Mailing Address - Phone:208-263-2040
Mailing Address - Fax:
Practice Address - Street 1:100 N 1ST AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1376
Practice Address - Country:US
Practice Address - Phone:208-263-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID10139177OtherREGENCE
ID806574200Medicaid
IDN5327OtherBLUE CROSS
ID10139177OtherREGENCE