Provider Demographics
NPI:1407026115
Name:GAYLE GOZDOR, PH.D. P.C.
Entity Type:Organization
Organization Name:GAYLE GOZDOR, PH.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GOZDOR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:313-730-2077
Mailing Address - Street 1:2881 MONROE ST
Mailing Address - Street 2:SUITE 201C
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3475
Mailing Address - Country:US
Mailing Address - Phone:313-730-2077
Mailing Address - Fax:248-562-7719
Practice Address - Street 1:2881 MONROE ST
Practice Address - Street 2:SUITE 201C
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3475
Practice Address - Country:US
Practice Address - Phone:313-730-2077
Practice Address - Fax:248-562-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007615103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F30675OtherBLUE CROSS BLUE SHIELD
MI0F30675OtherBLUE CROSS BLUE SHIELD
MI0M97570Medicare PIN