Provider Demographics
NPI:1487288510
Name:GARY W GOSSAGE LICENSED CLINICAL SOCIAL WORK
Entity type:Organization
Organization Name:GARY W GOSSAGE LICENSED CLINICAL SOCIAL WORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GOSSAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-400-2592
Mailing Address - Street 1:1910 PAYTON CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1327
Mailing Address - Country:US
Mailing Address - Phone:701-400-2592
Mailing Address - Fax:719-631-0577
Practice Address - Street 1:1910 PAYTON CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-1327
Practice Address - Country:US
Practice Address - Phone:701-400-2592
Practice Address - Fax:719-631-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-27
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty