Provider Demographics
NPI:1649336884
Name:GAMBLE, JOHN WYLIE (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WYLIE
Last Name:GAMBLE
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 1:190 ATO RD SE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-7861
Mailing Address - Country:US
Mailing Address - Phone:478-452-7500
Mailing Address - Fax:
Practice Address - Street 1:118 S WILKINSON ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3356
Practice Address - Country:US
Practice Address - Phone:478-452-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY000412103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCKZMedicare ID - Type Unspecified