Provider Demographics
NPI:1558422949
Name:DEVINE, GARY JAMES (MA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JAMES
Last Name:DEVINE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 E PHIL ELLENA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2223
Mailing Address - Country:US
Mailing Address - Phone:267-428-0321
Mailing Address - Fax:
Practice Address - Street 1:6757 GREENE STREET
Practice Address - Street 2:OFFICES AT SUMMIT PREBYTERIAN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3508
Practice Address - Country:US
Practice Address - Phone:267-428-0321
Practice Address - Fax:267-907-8586
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007555101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health