Provider Demographics
NPI:1699717348
Name:LOETHEN, GARY JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:LOETHEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E VETERANS ST
Mailing Address - Street 2:
Mailing Address - City:TOMAH
Mailing Address - State:WI
Mailing Address - Zip Code:54660-3105
Mailing Address - Country:US
Mailing Address - Phone:608-372-3971
Mailing Address - Fax:608-372-1263
Practice Address - Street 1:500 E VETERANS ST
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-3105
Practice Address - Country:US
Practice Address - Phone:608-372-3971
Practice Address - Fax:608-372-1263
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1914-057103TC0700X
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical