Provider Demographics
NPI:1386673614
Name:STAINBACK, GARY JUDSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JUDSON
Last Name:STAINBACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WINDEMERE CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-9246
Mailing Address - Country:US
Mailing Address - Phone:252-756-6468
Mailing Address - Fax:
Practice Address - Street 1:104 WINDEMERE CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-9246
Practice Address - Country:US
Practice Address - Phone:252-756-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1838103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical