Provider Demographics
NPI:1457829749
Name:SPAIN, GARRY BENJAMIN (LCSW)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:BENJAMIN
Last Name:SPAIN
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 1:6565 WYSTERIA LN
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-3787
Mailing Address - Country:US
Mailing Address - Phone:804-577-0439
Mailing Address - Fax:
Practice Address - Street 1:6565 WYSTERIA LN
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-3787
Practice Address - Country:US
Practice Address - Phone:804-577-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040107531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical