Provider Demographics
NPI:1881065340
Name:WARDLAW, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WARDLAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 COURT ST
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24504-1312
Mailing Address - Country:US
Mailing Address - Phone:434-455-1000
Mailing Address - Fax:434-485-8877
Practice Address - Street 1:3410 OLD FOREST RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2915
Practice Address - Country:US
Practice Address - Phone:434-455-1000
Practice Address - Fax:434-485-8877
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006346101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional