Provider Demographics
NPI:1972598381
Name:GURK, MITCHELL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:DAVID
Last Name:GURK
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 1:16 HASTINGS RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:MA
Mailing Address - Zip Code:01562-1408
Mailing Address - Country:US
Mailing Address - Phone:508-885-3861
Mailing Address - Fax:
Practice Address - Street 1:16 HASTINGS RD
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:MA
Practice Address - Zip Code:01562-1408
Practice Address - Country:US
Practice Address - Phone:508-885-3861
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMAPY2497103T00000X
MAMAMFT807106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA4FT807OtherLICENSE NUMBER
MAMAP42497OtherLICENSE NUMBER
MAMAP42497OtherLICENSE NUMBER
R44300Medicare UPIN