Provider Demographics
NPI:1750436374
Name:GAMACHE, MICHAEL P (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:GAMACHE
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 1:13902 N DALE MABRY HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2415
Mailing Address - Country:US
Mailing Address - Phone:813-264-9600
Mailing Address - Fax:813-264-9610
Practice Address - Street 1:13902 N DALE MABRY HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2415
Practice Address - Country:US
Practice Address - Phone:813-264-9600
Practice Address - Fax:813-264-9610
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3577103G00000X, 103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75662Medicare ID - Type UnspecifiedPROVIDER NUMBER