Provider Demographics
NPI:1205810090
Name:NUNNALLY, GARY (LCSW, DMIN)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:NUNNALLY
Suffix:
Gender:M
Credentials:LCSW, DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 CLEARVISTA PKWY
Mailing Address - Street 2:BLDG 7
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1400
Mailing Address - Country:US
Mailing Address - Phone:317-288-9942
Mailing Address - Fax:317-288-9945
Practice Address - Street 1:8202 CLEARVISTA PKWY
Practice Address - Street 2:BLDG 7
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1400
Practice Address - Country:US
Practice Address - Phone:317-288-9942
Practice Address - Fax:317-288-9945
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002418A101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100381890Medicaid
IN712310DDMedicare ID - Type Unspecified