Provider Demographics
NPI:1174651251
Name:FRY, GARY B (LCA066)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:FRY
Suffix:
Gender:M
Credentials:LCA066
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21617-1049
Mailing Address - Country:US
Mailing Address - Phone:410-758-1306
Mailing Address - Fax:410-758-2133
Practice Address - Street 1:205 N LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-1022
Practice Address - Country:US
Practice Address - Phone:410-758-1306
Practice Address - Fax:410-758-2133
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA066101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)