Provider Demographics
NPI:1033247226
Name:GOURVITZ, ROSS L (PHD)
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:L
Last Name:GOURVITZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S RIVER RD UNIT 33
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6721
Mailing Address - Country:US
Mailing Address - Phone:603-614-6016
Mailing Address - Fax:
Practice Address - Street 1:40 S RIVER RD UNIT 33
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6721
Practice Address - Country:US
Practice Address - Phone:603-614-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 018046103G00000X, 103TC0700X, 103TR0400X
NH1298103TC0700X, 103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation