Provider Demographics
NPI:1396721700
Name:GOTWAY, BERNARD J (PHD)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:J
Last Name:GOTWAY
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 1:1701 GATEWAY BLVD
Mailing Address - Street 2:SUITE 447
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3572
Mailing Address - Country:US
Mailing Address - Phone:972-918-9333
Mailing Address - Fax:972-783-8444
Practice Address - Street 1:1701 GATEWAY BLVD
Practice Address - Street 2:SUITE 447
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3572
Practice Address - Country:US
Practice Address - Phone:972-918-9333
Practice Address - Fax:972-783-8444
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX2-2116HSP103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00BY87OtherBLUE CROSS BLUE SHIELD
TX00BY87Medicare ID - Type Unspecified