Provider Demographics
NPI:1043686991
Name:GOLLOGLY, VINCENT THOMAS (PHD)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:THOMAS
Last Name:GOLLOGLY
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 1:11444 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1404
Mailing Address - Country:US
Mailing Address - Phone:253-223-2525
Mailing Address - Fax:
Practice Address - Street 1:11444 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1404
Practice Address - Country:US
Practice Address - Phone:253-223-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002233103TC0700X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities