Provider Demographics
NPI:1487715777
Name:ZIMMERMAN, GARY WILLIAM (PHD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WILLIAM
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 'F' STREET
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354
Mailing Address - Country:US
Mailing Address - Phone:209-578-4760
Mailing Address - Fax:209-578-4760
Practice Address - Street 1:1420 'F' STREET
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354
Practice Address - Country:US
Practice Address - Phone:209-578-4760
Practice Address - Fax:209-578-4760
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5588103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical