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General NPI Number Information
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NPI Number | 1760288716
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Entity Type | Individual
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Provider Name | MICHAEL GARY
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Gender | Male
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Dates
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Enumeration Date | 02/20/2025
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Last Update Date | 02/20/2025
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Provider Practice Location Address
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Address Line | 300 N SMITH ST
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City | CARBONDALE
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State | IL
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Zip | 62901-1131
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Country | US
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Telephone | 618-353-7245
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3892
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City | CARBONDALE
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State | IL
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Zip | 62902-3892
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 178.020293
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License Number State | IL
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