Provider Demographics
NPI:1629436068
Name:BAUMAN, GARY S (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:BAUMAN
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517
Mailing Address - Country:US
Mailing Address - Phone:770-354-3338
Mailing Address - Fax:
Practice Address - Street 1:300 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517
Practice Address - Country:US
Practice Address - Phone:770-354-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-31
Last Update Date:2016-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001821101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional