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General NPI Number Information
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NPI Number | 1598931578
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Entity Type | Organization
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Legal Business Name | PORT CITY PSYCHOTHERAPY AND PSYCHOLOGICAL SERVICES
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Dates
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Enumeration Date | 04/30/2008
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Last Update Date | 04/30/2008
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Provider Practice Location Address
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Address Line | 46 E ONEIDA ST
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City | OSWEGO
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State | NY
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Zip | 13126-2218
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Country | US
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Telephone | 315-342-2558
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Fax | 315-342-2046
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Provider Business Mailing Address
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Address Line | 46 E ONEIDA ST
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City | OSWEGO
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State | NY
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Zip | 13126-2218
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Country | US
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Telephone | 315-342-2558
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Fax | 315-342-2046
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. BROOKS B GUMP
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Credential | PHD
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Telephone | 315-342-2558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 013527
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License Number State | NY
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