Provider Demographics
NPI:1265714133
Name:GUMP, NATHANIEL WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:WILLIAM
Last Name:GUMP
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 1:408 SW MONROE AVE STE M236
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-7210
Mailing Address - Country:US
Mailing Address - Phone:541-250-0143
Mailing Address - Fax:
Practice Address - Street 1:408 SW MONROE AVE STE M236
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-7210
Practice Address - Country:US
Practice Address - Phone:541-250-0143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2738-57103TC1900X
OR2967103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling