Provider Demographics
NPI:1982775821
Name:WISHART, GARY AUSTIN (PSYD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:AUSTIN
Last Name:WISHART
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 VOLUNTEER PARKWAY
Mailing Address - Street 2:SUITE G
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620
Mailing Address - Country:US
Mailing Address - Phone:423-652-2212
Mailing Address - Fax:423-652-2212
Practice Address - Street 1:601 VOLUNTEER PARKWAY
Practice Address - Street 2:SUITE G
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-652-2212
Practice Address - Fax:423-652-2212
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001915103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA085256OtherANTHEM BCBS OF VA
TN242191000OtherMAGELLAN
TN4098126OtherBCBS OF TN MEDICAL
TN621618739OtherAARP
TN621618739OtherUNITED BEHAVIORAL HEALTH
TN621618739OtherCIGNA
TN621618739OtherUNITED HEALTHCARE
TN621618739OtherTRICARE
TN621618739OtherHORIZON HEALTH
TN0181971OtherBCBS OF TN
TN104229OtherVALUE OPTIONS
TN621618739OtherAETNA
TN621618739OtherJOHN DEERE HEALTHCARE
TN621618739OtherHORIZON HEALTH