Provider Demographics
NPI:1538414362
Name:GYST COUNSELING & WELLNESS LLC
Entity type:Organization
Organization Name:GYST COUNSELING & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:208-473-1263
Mailing Address - Street 1:11920 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5506
Mailing Address - Country:US
Mailing Address - Phone:208-473-1263
Mailing Address - Fax:
Practice Address - Street 1:1002 BLAINE ST
Practice Address - Street 2:SUITE 208
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5574
Practice Address - Country:US
Practice Address - Phone:208-901-9159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDW112925251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health