Provider Demographics
NPI:1609013952
Name:GOOTNICK, ANDREW T (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:T
Last Name:GOOTNICK
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 1:1000 5TH AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-6103
Mailing Address - Country:US
Mailing Address - Phone:415-457-1600
Mailing Address - Fax:
Practice Address - Street 1:1000 5TH AVE STE 5
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-6103
Practice Address - Country:US
Practice Address - Phone:415-457-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5743103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist