MEDICARE: GORDON MOOR WHEELER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	6509	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6509	OTHER	MA	LICD PSYCHOLOGIST PROVIDER
2	6509	OTHER	MA	LICD PSYCHOLOGY PROVIDER

General Provider Information

NPI Number	:	1639664576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GORDON MOOR WHEELER PHD

Provider Business Mailing Address
First Line	:	302 MOORE ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2516
Country	:	US
Telephone Number	:	831-917-1676
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 MOORE ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2516
Country	:	US
Telephone Number	:	831-917-1676
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2018
Last Update Date	:	06/23/2018

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Directions to “ GORDON MOOR WHEELER PHD” Practice Location

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