Provider Demographics
NPI:1851395784
Name:MASTERS, GARY (LCSW)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MASTERS
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:STE 3B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-578-1541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW03239104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3695900Medicaid
VA008907528Medicaid
TN3695901Medicare ID - Type Unspecified
VA008907528Medicaid
TN3695900Medicaid