Provider Demographics
NPI:1558782524
Name:MAYNE, GARY (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MAYNE
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 1:742 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2017
Mailing Address - Country:US
Mailing Address - Phone:315-703-2773
Mailing Address - Fax:315-703-2766
Practice Address - Street 1:742 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2017
Practice Address - Country:US
Practice Address - Phone:315-703-2773
Practice Address - Fax:315-703-2766
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03956111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical