Provider Demographics
NPI:1639664576
Name:WHEELER, GORDON MOOR (PHD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:MOOR
Last Name:WHEELER
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 1:302 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-2516
Mailing Address - Country:US
Mailing Address - Phone:831-917-1676
Mailing Address - Fax:
Practice Address - Street 1:302 MOORE ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-2516
Practice Address - Country:US
Practice Address - Phone:831-917-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6509103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6509OtherLICD PSYCHOLOGIST PROVIDER
MA6509OtherLICD PSYCHOLOGY PROVIDER