Provider Demographics
NPI:1043382732
Name:COURNOYER, GARY P (LICSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:P
Last Name:COURNOYER
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RIPTIDE ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835-2527
Mailing Address - Country:US
Mailing Address - Phone:401-842-1158
Mailing Address - Fax:
Practice Address - Street 1:342 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-1736
Practice Address - Country:US
Practice Address - Phone:401-842-1158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW000611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI3860-1OtherR.I. BLUE CROSS
RIISW00061OtherR.I. INDEP. SOC. WORKER