Basic Information
| Provider Information | |||||||||
| NPI: | 1881065340 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARDLAW | ||||||||
| FirstName: | GARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 COURT ST | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245041312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344551000 | ||||||||
| FaxNumber: | 4344858877 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 OLD FOREST RD | ||||||||
| Address2: | |||||||||
| City: | LYNCHBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245012915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344551000 | ||||||||
| FaxNumber: | 4344858877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701006346 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.