MEDICARE: DR. LAURENCE ROBERT GORE PH.D.

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	103TC0700X	Clinical Psychologist	P.7116	OH
2	103TC0700X	Clinical Psychologist	PSY17037	CA

General Provider Information

NPI Number	:	1720129794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURENCE ROBERT GORE PH.D.

Provider Business Mailing Address
First Line	:	3244 HENDERSON RD
Second Line	:	STE 2
City	:	COLUMBUS
State	:	OH
Zip	:	43220-7300
Country	:	US
Telephone Number	:	310-448-9510
Fax Number	:	310-553-2003

Provider Business Practice Location Address
First Line	:	455 N. SHAWNEE LN
Second Line	:
City	:	CHILLICOTHEE
State	:	OH
Zip	:	45601-4145
Country	:	US
Telephone Number	:	740-779-4888
Fax Number	:

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

Provider Enumeration Date	:	02/10/2007
Last Update Date	:	04/02/2024

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