Provider Demographics
NPI:1740529817
Name:BAILEY, GOMER RAY JR (PHD)
Entity type:Individual
Prefix:MR
First Name:GOMER
Middle Name:RAY
Last Name:BAILEY
Suffix:JR
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 1:1420 WILLSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2448
Mailing Address - Country:US
Mailing Address - Phone:216-702-1225
Mailing Address - Fax:
Practice Address - Street 1:12201 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4310
Practice Address - Country:US
Practice Address - Phone:216-707-3478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6583103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0218310Medicaid