Provider Demographics
NPI:1346520145
Name:GARY, BRIAN (SOCIAL WORK)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GARY
Suffix:
Gender:M
Credentials:SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 PARK AVE NW
Mailing Address - Street 2:PO BOX X
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-9500
Mailing Address - Country:US
Mailing Address - Phone:218-694-6164
Mailing Address - Fax:218-694-3535
Practice Address - Street 1:216 PARK AVE NW
Practice Address - Street 2:PO BOX X
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-9500
Practice Address - Country:US
Practice Address - Phone:218-694-6164
Practice Address - Fax:218-694-3535
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
27OtherSOCIAL SERVICES