Provider Demographics
NPI:1457356982
Name:HORNBACK, GREGORY D (LPC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:D
Last Name:HORNBACK
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:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-0332
Mailing Address - Country:US
Mailing Address - Phone:540-526-4673
Mailing Address - Fax:540-591-9911
Practice Address - Street 1:1450 ROANOKE RD
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-2935
Practice Address - Country:US
Practice Address - Phone:540-526-4673
Practice Address - Fax:540-591-9914
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002919101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010029791Medicaid