Healthcare Provider Details

I. General information

NPI: 1104004787
Provider Name (Legal Business Name): RANDY JOSEPH GAGE PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 S WEBSTER AVE
GREEN BAY WI
54301-3959
US

IV. Provider business mailing address

430 S WEBSTER AVE
GREEN BAY WI
54301-3959
US

V. Phone/Fax

Practice location:
  • Phone: 920-837-3530
  • Fax:
Mailing address:
  • Phone: 920-837-3530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number2614-057
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2614-057
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2614-057
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2614-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: