Provider Demographics
NPI:1538714795
Name:OSTERLOTH, GINA L (BA, CADC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:L
Last Name:OSTERLOTH
Suffix:
Gender:F
Credentials:BA, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 S 16TH ST STE 118
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-3514
Mailing Address - Country:US
Mailing Address - Phone:208-297-8889
Mailing Address - Fax:208-485-9475
Practice Address - Street 1:540 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-3513
Practice Address - Country:US
Practice Address - Phone:208-297-8889
Practice Address - Fax:208-485-9475
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID11675101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)