Provider Demographics
NPI:1174531420
Name:PURDY, GAIL J (PHD, BCBA)
Entity type:Individual
Prefix:DR
First Name:GAIL
Middle Name:J
Last Name:PURDY
Suffix:
Gender:F
Credentials:PHD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11842 W WATERWAY DR
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34448-7312
Mailing Address - Country:US
Mailing Address - Phone:352-628-7611
Mailing Address - Fax:352-628-7644
Practice Address - Street 1:11842 W WATERWAY DR
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34448-7312
Practice Address - Country:US
Practice Address - Phone:352-628-7611
Practice Address - Fax:352-628-7644
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5901103T00000X, 103TC0700X
103TB0200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689827196Medicaid