Healthcare Provider Details

I. General information

NPI: 1275840795
Provider Name (Legal Business Name): GARY RAE LITTLE JR. LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2010
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HOSPITAL LOOP STE 276
FAIRCHILD AIR FORCE BASE WA
99011-8704
US

IV. Provider business mailing address

1621 E 36TH AVE
SPOKANE WA
99203-4039
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-2687
  • Fax:
Mailing address:
  • Phone: 208-412-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-30498
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: