Provider Demographics
NPI:1104902022
Name:EMANUEL, GARY VICTOR (PHD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:VICTOR
Last Name:EMANUEL
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 1:4933 AUBURN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814
Mailing Address - Country:US
Mailing Address - Phone:301-986-8020
Mailing Address - Fax:301-951-5286
Practice Address - Street 1:4933 AUBURN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-986-8020
Practice Address - Fax:301-951-5286
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD689103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
491316Medicare ID - Type Unspecified