Provider Demographics
NPI:1356474092
Name:VAN GORP, WILFRED (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILFRED
Middle Name:
Last Name:VAN GORP
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 1:240 CENTRAL PARK S APT 2B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1429
Mailing Address - Country:US
Mailing Address - Phone:212-247-1350
Mailing Address - Fax:
Practice Address - Street 1:240 CENTRAL PARK S APT 2B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1429
Practice Address - Country:US
Practice Address - Phone:212-247-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071007843103G00000X
NY12676103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist