Provider Demographics
NPI:1982373320
Name:GONZAGA, KEVIN PACIFICO TAPP (PHD)
Entity type:Individual
Prefix:DR
First Name:KEVIN PACIFICO
Middle Name:TAPP
Last Name:GONZAGA
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 1:14 MAINE ST STE 309
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2033
Mailing Address - Country:US
Mailing Address - Phone:207-607-4022
Mailing Address - Fax:
Practice Address - Street 1:14 MAINE ST STE 309
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2033
Practice Address - Country:US
Practice Address - Phone:076-074-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS2607103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist