| Doctor Name: | BRADLEY DEAN GAULT |
| NPI Number: | 1316396062 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | MA |
| License Number: | 859 |
| Business Practice Address: | 98 Liberty Ln Mineral Wells, WV - 261501605 |
| Business Phone Number: | 3044822959 |
| Business Fax Number: | |
| Mailing Address: | 98 Liberty Ln, MINERAL WELLS |
| State: | WV |
| Postal Code: | 261501605 |
| Phone Number: | 3044822959 |
| Fax Number: | |
| NPI Enumeration Date: | 06/03/2016 |
| NPI Last Update Date: | 06/03/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC2200X |
| License Number: | 859 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WV |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical Child & Adolescent |
| Taxonomy Definition: | |