Provider Demographics
NPI:1023140571
Name:GOSSELIN, PHILIP WENNEIS (PHD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:WENNEIS
Last Name:GOSSELIN
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 1:41 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-1121
Mailing Address - Country:US
Mailing Address - Phone:413-549-4900
Mailing Address - Fax:413-773-9799
Practice Address - Street 1:41 SUMMER ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-1121
Practice Address - Country:US
Practice Address - Phone:413-549-4900
Practice Address - Fax:413-773-9799
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6770103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50494Medicare ID - Type Unspecified