Provider Demographics
NPI:1437206521
Name:ROTFUS, GARY HOWARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:HOWARD
Last Name:ROTFUS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5265 PROVIDENCE RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4206
Mailing Address - Country:US
Mailing Address - Phone:757-467-9500
Mailing Address - Fax:757-467-9560
Practice Address - Street 1:5265 PROVIDENCE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4206
Practice Address - Country:US
Practice Address - Phone:757-467-9500
Practice Address - Fax:757-467-9560
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040005521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0089022577Medicaid
VA0089022577Medicaid