Provider Demographics
NPI:1215638028
Name:WISDOM, GAVIN JOSEPH (MSW, LAC, SWLC)
Entity type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:JOSEPH
Last Name:WISDOM
Suffix:
Gender:M
Credentials:MSW, LAC, SWLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 3RD AVE E
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-4907
Mailing Address - Country:US
Mailing Address - Phone:303-601-1536
Mailing Address - Fax:
Practice Address - Street 1:2825 STOCKYARD RD STE A11
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1544
Practice Address - Country:US
Practice Address - Phone:406-543-5531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LAC-LIC-62611101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)