Provider Demographics
NPI:1568519866
Name:INCORVAIA, GARY J (LISW-S)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:INCORVAIA
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 MONROE ST, BLDG B, STE 3
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2263
Mailing Address - Country:US
Mailing Address - Phone:419-727-1200
Mailing Address - Fax:419-727-1200
Practice Address - Street 1:5800 MONROE ST, BLDG B, STE 3
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2263
Practice Address - Country:US
Practice Address - Phone:419-727-1200
Practice Address - Fax:419-727-1200
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010883671041C0700X
OHI-0071361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11586146OtherCAQH
OH-0162066Medicaid