Provider Demographics
NPI:1962804757
Name:REDFORD, GARY SEAN (LPC, NCC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:SEAN
Last Name:REDFORD
Suffix:
Gender:M
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12930 N RIO VISTA RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-5007
Mailing Address - Country:US
Mailing Address - Phone:208-226-6059
Mailing Address - Fax:
Practice Address - Street 1:12930 N RIO VISTA RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-5007
Practice Address - Country:US
Practice Address - Phone:208-226-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5620101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional