Provider Demographics
NPI:1902189061
Name:GAYNOR, JOHN P JR (LSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:GAYNOR
Suffix:JR
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4641 ROOSEVELT BLVD
Mailing Address - Street 2:ORLEANS BLDG
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2343
Mailing Address - Country:US
Mailing Address - Phone:215-742-7811
Mailing Address - Fax:215-831-2929
Practice Address - Street 1:4641 ROOSEVELT BLVD
Practice Address - Street 2:ORLEANS BLDG
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2343
Practice Address - Country:US
Practice Address - Phone:215-831-2836
Practice Address - Fax:215-831-2929
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW009349L104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker