Healthcare Provider Details

I. General information

NPI: 1922011584
Provider Name (Legal Business Name): LARRY M GERSTENHABER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5617 MAXWELL PL
WILMINGTON NC
28409-2966
US

IV. Provider business mailing address

PO BOX 16310
WILMINGTON NC
28408-6310
US

V. Phone/Fax

Practice location:
  • Phone: 910-742-9243
  • Fax: 888-746-1787
Mailing address:
  • Phone: 910-742-9243
  • Fax: 888-746-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0493
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: