Provider Demographics
NPI:1629077136
Name:GORAL, MARK ANTHONY (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:GORAL
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W RIDGE AVE STE J
Mailing Address - Street 2:
Mailing Address - City:SHARPSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16150-1282
Mailing Address - Country:US
Mailing Address - Phone:724-962-3125
Mailing Address - Fax:724-962-3235
Practice Address - Street 1:100 W RIDGE AVE STE J
Practice Address - Street 2:
Practice Address - City:SHARPSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16150-1282
Practice Address - Country:US
Practice Address - Phone:724-962-3125
Practice Address - Fax:724-962-3235
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008187L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGO115812OtherHIGHMARK BLUE SHIELD
PA0017090360003Medicaid
PA462544OtherVALUE OPTIONS
S67673Medicare UPIN
PA0017090360003Medicaid