Provider Demographics
NPI:1205087319
Name:FUTCH, GARY GLENN (PSYD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:GLENN
Last Name:FUTCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 LAMBTON DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8099
Mailing Address - Country:US
Mailing Address - Phone:318-451-5854
Mailing Address - Fax:
Practice Address - Street 1:309 SAINT JULIEN AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4655
Practice Address - Country:US
Practice Address - Phone:337-406-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical