Provider Demographics
NPI:1275515009
Name:GAYNOR, MARK LESLIE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LESLIE
Last Name:GAYNOR
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WHITNEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-1283
Mailing Address - Country:US
Mailing Address - Phone:203-865-0865
Mailing Address - Fax:203-865-0093
Practice Address - Street 1:100 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-865-0865
Practice Address - Fax:203-865-0093
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0009301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical