Basic Information
Provider Information
NPI: 1003805078
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHASE
FirstName: GARY
MiddleName: H.
NamePrefix: DR.
NameSuffix:  
Credential: PH.D. PSYCHOLOGIST
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6136 FRISCO SQUARE BLVD
Address2: SUITE 400
City: FRISCO
State: TX
PostalCode: 750343246
CountryCode: US
TelephoneNumber: 4693623334
FaxNumber: 9723340347
Practice Location
Address1: 6136 FRISCO SQUARE BLVD
Address2: SUITE 400
City: FRISCO
State: TX
PostalCode: 750343246
CountryCode: US
TelephoneNumber: 4693623334
FaxNumber: 9723340347
Other Information
ProviderEnumerationDate: 10/20/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103T00000X32373TXX Behavioral Health & Social Service ProvidersPsychologist 
103TC0700X32373TXX Behavioral Health & Social Service ProvidersPsychologistClinical
103TC1900X32373TXX Behavioral Health & Social Service ProvidersPsychologistCounseling
103TF0000X32373TXX Behavioral Health & Social Service ProvidersPsychologistFamily
103TH0100X32373TXX Behavioral Health & Social Service ProvidersPsychologistHealth Service

ID Information
IDTypeStateIssuerDescription
8031401 UNICAREOTHER
0024LV01TXBCBSOTHER
21743701 MANAGED HEALTH NETWORKOTHER
753979901 AETNAOTHER
06300301 VALUE OPTIONSOTHER


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