Provider Demographics
NPI:1679670319
Name:SEYBOLD, GINA WOLFE (LICENSED CLINICAL PR)
Entity type:Individual
Prefix:MS
First Name:GINA
Middle Name:WOLFE
Last Name:SEYBOLD
Suffix:
Gender:F
Credentials:LICENSED CLINICAL PR
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:E
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSED CLINICAL PR
Mailing Address - Street 1:1408 W HAYS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-387-0778
Mailing Address - Fax:208-336-7125
Practice Address - Street 1:1408 W HAYS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-387-0778
Practice Address - Fax:208-336-7125
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010017707OtherREGENCE BLUE SHIELD
IDQ6983OtherBLUE CROSS OF ID