Provider Demographics
NPI:1417652603
Name:GOURLEY, RAYMOND WADE
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:WADE
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4908
Mailing Address - Country:US
Mailing Address - Phone:856-534-7233
Mailing Address - Fax:215-732-8454
Practice Address - Street 1:313 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4908
Practice Address - Country:US
Practice Address - Phone:215-732-8244
Practice Address - Fax:215-732-8454
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health