Provider Demographics
NPI:1528163011
Name:DE GASTA, GARY M (LICSW)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:M
Last Name:DE GASTA
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 HAWK PINE RD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-9631
Mailing Address - Country:US
Mailing Address - Phone:802-649-3533
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-0001
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1006331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical