Provider Demographics
NPI:1245299361
Name:FUSCIARDI, GARY JOSEPH (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOSEPH
Last Name:FUSCIARDI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52480 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-3163
Mailing Address - Country:US
Mailing Address - Phone:586-323-0696
Mailing Address - Fax:586-731-8393
Practice Address - Street 1:8061 21 MILE RD
Practice Address - Street 2:SUITE #4
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317-4311
Practice Address - Country:US
Practice Address - Phone:586-323-0696
Practice Address - Fax:586-731-8393
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5088220OtherAETNA
MI042893OtherVALUE OPTIONS