Basic Information
| Provider Information | |||||||||
| NPI: | 1952349193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAYNOR | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672033602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607600 | ||||||||
| FaxNumber: | 3163837925 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 N AMIDON AVE | ||||||||
| Address2: | STE. 130 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672032117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166607675 | ||||||||
| FaxNumber: | 3168321571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 0405 | KS | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 022101 | 01 | KS | BLUE CROSS | OTHER | 4205 | 01 | KS | PREFERRED HEALTH SYSTEMS | OTHER | 2144774 | 01 | KS | CIGNA | OTHER | PV115577 | 01 | KS | AMERICAN PSYCH SYSTEMS | OTHER |