Provider Demographics
NPI:1083760714
Name:GATES, HENRY (PHD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:GATES
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 1:109 RIVER ST
Mailing Address - Street 2:APT. 1B
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3817
Mailing Address - Country:US
Mailing Address - Phone:617-354-4422
Mailing Address - Fax:
Practice Address - Street 1:100 LEDGEWOOD PL
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCKLAND
Practice Address - State:MA
Practice Address - Zip Code:02370-1075
Practice Address - Country:US
Practice Address - Phone:781-871-6550
Practice Address - Fax:781-871-5973
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4356103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04311Medicare ID - Type Unspecified