Provider Demographics
NPI:1164505731
Name:GONTANG, RICHARD ALAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:GONTANG
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 1:5691 COLUMBIA PIKE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22041
Mailing Address - Country:US
Mailing Address - Phone:703-998-5606
Mailing Address - Fax:703-998-5608
Practice Address - Street 1:5691 COLUMBIA PIKE
Practice Address - Street 2:SUITE 200
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22041
Practice Address - Country:US
Practice Address - Phone:703-998-5606
Practice Address - Fax:703-998-5608
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003411103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
185384OtherANTHEM
28110017OtherCARE FIRST