Healthcare Provider Details

I. General information

NPI: 1093828816
Provider Name (Legal Business Name): LARRY E GAINES PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19449 SINGING HILLS DR
NORTHRIDGE CA
91326-1719
US

IV. Provider business mailing address

19449 SINGING HILLS DR
NORTHRIDGE CA
91326-1719
US

V. Phone/Fax

Practice location:
  • Phone: 818-360-1514
  • Fax:
Mailing address:
  • Phone: 818-360-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY10887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: