Provider Demographics
NPI:1326455320
Name:ADKISSON, GARY JR (LLPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:ADKISSON
Suffix:JR
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30500 VAN DYKE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30500 VAN DYKE AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2195
Practice Address - Country:US
Practice Address - Phone:586-558-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014373101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor