Provider Demographics
NPI:1780948950
Name:GARY A. WISHART, PSY.D., PLLC
Entity type:Organization
Organization Name:GARY A. WISHART, PSY.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:WISHART
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:423-652-2212
Mailing Address - Street 1:601 VOLUNTEER PKWY
Mailing Address - Street 2:SUITE G
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-3653
Mailing Address - Country:US
Mailing Address - Phone:423-652-2212
Mailing Address - Fax:423-652-2212
Practice Address - Street 1:601 VOLUNTEER PKWY
Practice Address - Street 2:SUITE G
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-3653
Practice Address - Country:US
Practice Address - Phone:423-652-2212
Practice Address - Fax:423-652-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-02
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001915103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0004551019OtherAETNA
TN00610001154OtherUNITED HEALTHCARE
TN104229OtherVALUE OPTIONS
TN0181971OtherBLUE CROSS/BLUE SHIELD
TN1982775821OtherALL INSURANCE CARRIERS AND MEDICARE
VA085256OtherANTHEM OF VIRGINIA
TN=========OtherUNITED BEHAVIORAL HEALTH
VA085256OtherANTHEM OF VIRGINIA
TN=========OtherUNITED BEHAVIORAL HEALTH