Healthcare Provider Details

I. General information

NPI: 1568594075
Provider Name (Legal Business Name): GORDON G BALL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CENTRAL PARK W APT 1I
NEW YORK NY
10023-7206
US

IV. Provider business mailing address

175 W 73RD ST APT 5E
NEW YORK NY
10023-2932
US

V. Phone/Fax

Practice location:
  • Phone: 212-957-3677
  • Fax: 212-787-4780
Mailing address:
  • Phone: 212-957-3677
  • Fax: 212-787-4780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number004919-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: