=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235497744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD GAINES, PH.D., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2012
-----------------------------------------------------
Last Update Date | 06/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 W RIDGEWOOD AVE
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450-3199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-444-9866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 DEER TRL N
-----------------------------------------------------
City | RAMSEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07446-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-314-0515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RICHARD WILLIAM GAINES
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 201-444-9866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 3956
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------