Provider Demographics
NPI:1043662414
Name:HOWARD, GARY SCOTT (STUDENT/INTERN)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:SCOTT
Last Name:HOWARD
Suffix:
Gender:M
Credentials:STUDENT/INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13750 CROSSTOWN DR NW
Mailing Address - Street 2:MOLLY PROFESSIONAL CENTER ,PHASE II #207
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5853
Mailing Address - Country:US
Mailing Address - Phone:763-755-6290
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR NW
Practice Address - Street 2:MOLLY PROFESSIONAL CENTER ,PHASE II #207
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5853
Practice Address - Country:US
Practice Address - Phone:763-755-6290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)