Provider Demographics
NPI:1780904516
Name:GACONO, CARL BRUCE (PHD, ABAP)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:BRUCE
Last Name:GACONO
Suffix:
Gender:M
Credentials:PHD, ABAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 140633
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78714
Mailing Address - Country:US
Mailing Address - Phone:512-278-0198
Mailing Address - Fax:512-278-0198
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:N-5
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-278-0198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30591103T00000X
CA11432103TC0700X
103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic