Basic Information
Provider Information | |||||||||
NPI: | 1366461014 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CURTIS | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 998 | ||||||||
Address2: |   | ||||||||
City: | CHURCHVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 244210900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108252281 | ||||||||
FaxNumber: | 4108250757 | ||||||||
Practice Location | |||||||||
Address1: | 1407 YORK RD | ||||||||
Address2: | SUITE309 | ||||||||
City: | LUTHERVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 210936097 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4108252281 | ||||||||
FaxNumber: | 4108250757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 11/05/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 03714 | MD | Y |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TC1900X | 3714 | MD | N |   | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TC0700X | 0810003695 | VA | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.