Provider Demographics
NPI:1275840795
Name:LITTLE, GARY RAE JR (LICSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:RAE
Last Name:LITTLE
Suffix:JR
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 1:1621 E 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-4039
Mailing Address - Country:US
Mailing Address - Phone:208-412-2111
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP STE 276
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AIR FORCE BASE
Practice Address - State:WA
Practice Address - Zip Code:99011-8704
Practice Address - Country:US
Practice Address - Phone:509-247-2687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-30498104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker