Provider Demographics
NPI:1841229143
Name:LONGWITH, GARY A (PSYD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:A
Last Name:LONGWITH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10627
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93389-0627
Mailing Address - Country:US
Mailing Address - Phone:661-327-4252
Mailing Address - Fax:661-327-3409
Practice Address - Street 1:432 TRUXTUN AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-5316
Practice Address - Country:US
Practice Address - Phone:661-327-4252
Practice Address - Fax:661-327-3409
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18868103TC0700X, 103TF0200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP59295Medicare UPIN
CAZZZ01641ZMedicare ID - Type Unspecified