Provider Demographics
NPI:1093828816
Name:GAINES, LARRY E (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:E
Last Name:GAINES
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 1:19449 SINGING HILLS DR
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-1719
Mailing Address - Country:US
Mailing Address - Phone:818-360-1514
Mailing Address - Fax:
Practice Address - Street 1:19449 SINGING HILLS DR
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-1719
Practice Address - Country:US
Practice Address - Phone:818-360-1514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10887103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP10887Medicare ID - Type UnspecifiedPSYCHOLOGIST