Provider Demographics
NPI:1679946990
Name:SCHWANKE, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:SCHWANKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5249 DUKE ST
Mailing Address - Street 2:SUITE #200
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-2926
Mailing Address - Country:US
Mailing Address - Phone:863-232-6489
Mailing Address - Fax:
Practice Address - Street 1:5249 DUKE ST
Practice Address - Street 2:SUITE #200
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2926
Practice Address - Country:US
Practice Address - Phone:863-232-6489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006380101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701006380OtherLICENSE NUMBER