Provider Demographics
NPI:1861589327
Name:IWAMASA, GAYLE Y (PHD, HSPP)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:Y
Last Name:IWAMASA
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6991 E 375 S
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-9461
Mailing Address - Country:US
Mailing Address - Phone:765-742-1826
Mailing Address - Fax:
Practice Address - Street 1:1415 SALEM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-4100
Practice Address - Country:US
Practice Address - Phone:765-742-1816
Practice Address - Fax:765-742-2557
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040904A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical