Provider Demographics
NPI:1750395620
Name:AMMONS, GARY WAYNE (MS)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:WAYNE
Last Name:AMMONS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1371 OVERHILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2414
Mailing Address - Country:US
Mailing Address - Phone:304-363-8583
Mailing Address - Fax:
Practice Address - Street 1:UNITED SUMMIT CENTER
Practice Address - Street 2:#6 HOSPITAL PLAZA
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301
Practice Address - Country:US
Practice Address - Phone:304-623-5661
Practice Address - Fax:304-623-2989
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1648101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional