Provider Demographics
NPI:1912724162
Name:GIST, LAMONTIE
Entity type:Individual
Prefix:
First Name:LAMONTIE
Middle Name:
Last Name:GIST
Suffix:
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 1:132 SCONSET CIR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7175
Mailing Address - Country:US
Mailing Address - Phone:419-936-4567
Mailing Address - Fax:
Practice Address - Street 1:132 SCONSET CIR
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7175
Practice Address - Country:US
Practice Address - Phone:419-936-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician