Provider Demographics
NPI:1679636807
Name:GAYNOR, RICHARD JAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAY
Last Name:GAYNOR
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 1:4111 SPRINGROCK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-1931
Mailing Address - Country:US
Mailing Address - Phone:513-385-3761
Mailing Address - Fax:
Practice Address - Street 1:2450 KIPLING AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-6600
Practice Address - Country:US
Practice Address - Phone:513-542-4177
Practice Address - Fax:513-542-9222
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2620103TC0700X
KY298103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0936812Medicaid
OH0936812Medicaid