Provider Demographics
NPI:1518328707
Name:WHITE, GARY MICHAEL (LGSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:WHITE
Suffix:
Gender:M
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 LOCUST AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-1436
Mailing Address - Country:US
Mailing Address - Phone:304-366-0700
Mailing Address - Fax:304-366-9529
Practice Address - Street 1:1322 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1436
Practice Address - Country:US
Practice Address - Phone:304-366-0700
Practice Address - Fax:304-366-9529
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944697104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker