Provider Demographics
NPI:1164026217
Name:WARD, GARY WAYNE (DMIN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:WARD
Suffix:
Gender:M
Credentials:DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 FAIRMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-3427
Mailing Address - Country:US
Mailing Address - Phone:817-504-0062
Mailing Address - Fax:
Practice Address - Street 1:2508 LITTLE RD STE 200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-1301
Practice Address - Country:US
Practice Address - Phone:682-232-4453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66728101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional