Provider Demographics
NPI:1285465591
Name:GERRY, MARK SCOTT II
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:SCOTT
Last Name:GERRY
Suffix:II
Gender:M
Credentials:
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 871545
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1545
Mailing Address - Country:US
Mailing Address - Phone:907-376-4534
Mailing Address - Fax:907-376-2348
Practice Address - Street 1:26731 W POINT MACKENZIE RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-8709
Practice Address - Country:US
Practice Address - Phone:907-376-4534
Practice Address - Fax:907-376-2348
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5183101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)