Provider Demographics
NPI:1588106801
Name:MARY GIENCKE
Entity type:Organization
Organization Name:MARY GIENCKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIENCKE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:757-490-0377
Mailing Address - Street 1:609 INDEPENDENCE PKWY
Mailing Address - Street 2:SUITE 115
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5209
Mailing Address - Country:US
Mailing Address - Phone:757-490-0377
Mailing Address - Fax:
Practice Address - Street 1:609 INDEPENDENCE PKWY
Practice Address - Street 2:SUITE 115
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5209
Practice Address - Country:US
Practice Address - Phone:757-490-0377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006852251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health