Provider Demographics
NPI:1760701296
Name:CHADWICK, GARY CORTLAND (LPC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CORTLAND
Last Name:CHADWICK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5761 S CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2911
Mailing Address - Country:US
Mailing Address - Phone:816-284-0108
Mailing Address - Fax:
Practice Address - Street 1:10 S EUCLID AVE STE C
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3809
Practice Address - Country:US
Practice Address - Phone:617-379-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2010027858101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1760701296Medicaid