Provider Demographics
NPI:1780118380
Name:GAYNOR, SCOTT (PHD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:GAYNOR
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 1:1903 W MICHIGAN AVE
Mailing Address - Street 2:PSYCHOLOGY DEPARTMENT
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-5200
Mailing Address - Country:US
Mailing Address - Phone:269-387-4482
Mailing Address - Fax:269-387-4550
Practice Address - Street 1:1000 OAKLAND DR
Practice Address - Street 2:PSYCHOLOGY CLINIC
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1282
Practice Address - Country:US
Practice Address - Phone:269-387-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011933103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical