Provider Demographics
NPI:1114495132
Name:GEORGE, GARY ANTONIO (LCSWA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ANTONIO
Last Name:GEORGE
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2854 SUMMERGROVE CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-6456
Mailing Address - Country:US
Mailing Address - Phone:910-445-6881
Mailing Address - Fax:
Practice Address - Street 1:4822 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6668
Practice Address - Country:US
Practice Address - Phone:704-532-5757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0129321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical