Provider Demographics
NPI:1124170337
Name:EATON, GAYLE (LCSW)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:
Last Name:EATON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:ID
Mailing Address - Zip Code:83611-1330
Mailing Address - Country:US
Mailing Address - Phone:208-382-4242
Mailing Address - Fax:208-382-5081
Practice Address - Street 1:402 OLD STATE HWY
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:ID
Practice Address - Zip Code:83611
Practice Address - Country:US
Practice Address - Phone:208-382-4242
Practice Address - Fax:208-382-5081
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW8531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL8539OtherBLUE CROSS OF ID
ID000010016900OtherREGENCE BLUE SHIELD OF ID
ID000010016900OtherREGENCE BLUE SHIELD OF ID
P15253Medicare UPIN