Provider Demographics
NPI:1588073787
Name:WAKIM, GRETCHEN
Entity type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:
Last Name:WAKIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5323
Mailing Address - Country:US
Mailing Address - Phone:440-357-6171
Mailing Address - Fax:440-352-1257
Practice Address - Street 1:585 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-5323
Practice Address - Country:US
Practice Address - Phone:440-357-6171
Practice Address - Fax:440-352-1257
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20870491103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool