MEDICARE: DR. SAMUEL THOMAS GONTKOVSKY PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3446-57	WI
2	103TC0700X	Clinical Psychologist	723	NE
3	103TC0700X	Clinical Psychologist	42692	MS
4	103TC0700X	Clinical Psychologist	7285	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801954920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL THOMAS GONTKOVSKY PSY.D.

Provider Business Mailing Address
First Line	:	455 SHAWNEE LN
Second Line	:
City	:	CHILLICOTHEE
State	:	OH
Zip	:	45601-4145
Country	:	US
Telephone Number	:	740-779-4888
Fax Number	:	740-779-4898

Provider Business Practice Location Address
First Line	:	455 SHAWNEE LN
Second Line	:
City	:	CHILLICOTHEE
State	:	OH
Zip	:	45601-4145
Country	:	US
Telephone Number	:	740-779-4888
Fax Number	:	740-779-4898

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	12/14/2022

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