Healthcare Provider Details

I. General information

NPI: 1982373320
Provider Name (Legal Business Name): KEVIN PACIFICO TAPP GONZAGA PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 W RIVER RD
AUGUSTA ME
04330-8144
US

IV. Provider business mailing address

12 CROSSING WAY SUITE 3 #1047
AUGUSTA ME
04330
US

V. Phone/Fax

Practice location:
  • Phone: 207-816-8043
  • Fax: 207-517-1402
Mailing address:
  • Phone: 207-816-8043
  • Fax: 207-517-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS2607
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: