Healthcare Provider Details

I. General information

NPI: 1669627477
Provider Name (Legal Business Name): RICHARD ALBERT GAUDET PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 11/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 WALNUT LN
PHILADELPHIA PA
19128-1742
US

IV. Provider business mailing address

535 WALNUT LN
PHILADELPHIA PA
19128-1742
US

V. Phone/Fax

Practice location:
  • Phone: 215-298-4515
  • Fax:
Mailing address:
  • Phone: 215-298-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSO 16156
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 00052525
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number35S100457500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: