Healthcare Provider Details

I. General information

NPI: 1780904516
Provider Name (Legal Business Name): CARL BRUCE GACONO PH.D., ABAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 SPICEWOOD SPRINGS RD N-5
AUSTIN TX
78759-8661
US

IV. Provider business mailing address

P.O. BOX 140633
AUSTIN TX
78714
US

V. Phone/Fax

Practice location:
  • Phone: 512-278-0198
  • Fax:
Mailing address:
  • Phone: 512-278-0198
  • Fax: 512-278-0198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number30591
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11432
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: