Provider Demographics
NPI:1538295829
Name:STOVER, GARY DEAN (MA, LP)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DEAN
Last Name:STOVER
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 CADILLAC DR
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26104-2114
Mailing Address - Country:US
Mailing Address - Phone:304-485-5578
Mailing Address - Fax:
Practice Address - Street 1:2121 7TH ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3803
Practice Address - Country:US
Practice Address - Phone:304-485-1721
Practice Address - Fax:304-485-6710
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV873103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV873OtherPSYCHOLOGY LICENSE