Provider Demographics
NPI:1427452572
Name:BLACK, GARY EDWARD (LMP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:EDWARD
Last Name:BLACK
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SILVERTHISTLE RD
Mailing Address - Street 2:
Mailing Address - City:WINLOCK
Mailing Address - State:WA
Mailing Address - Zip Code:98596-9731
Mailing Address - Country:US
Mailing Address - Phone:360-304-9126
Mailing Address - Fax:
Practice Address - Street 1:205 CLARK PL SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4062
Practice Address - Country:US
Practice Address - Phone:360-570-0401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60326924225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist