Healthcare Provider Details

I. General information

NPI: 1174930499
Provider Name (Legal Business Name): GEORGE ADAM GAITHER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 N WHEELING AVE
MUNCIE IN
47303-1602
US

IV. Provider business mailing address

2205 N WHEELING AVE
MUNCIE IN
47303-1602
US

V. Phone/Fax

Practice location:
  • Phone: 765-287-1922
  • Fax: 765-287-9017
Mailing address:
  • Phone: 765-287-1922
  • Fax: 765-287-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number99062803A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: