Provider Demographics
NPI:1295155893
Name:GAURA, GERALD J JR (LMFT)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:J
Last Name:GAURA
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 DOWD AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-2441
Mailing Address - Country:US
Mailing Address - Phone:860-451-9307
Mailing Address - Fax:855-377-9142
Practice Address - Street 1:10 DEPOT ST STE 100
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06019-4101
Practice Address - Country:US
Practice Address - Phone:860-323-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1666106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT181523Medicaid