Samuel Thomas Gontkovsky, PSY.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

7285 Issued in OH

Practice address

455 Shawnee LN
Chillicothe, OH 45601-4145

Phone

(740) 779-4888

Fax

(740) 779-4898

NPI assigned

Dec 4, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Merit-based Incentive Payment System (MIPS)

Final score

82.93 of 100Reported as group

Quality

64.42

Promoting interoperability

99

Improvement activities

40

Cost

73.2

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

Flagged The directory lists this NPI on an HHS exclusion list. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Adena Medical Group LLC

  • Family Medicine Physician
  • Chillicothe, OH
  • NPI 1235468083
  Medicare reassignment NPD
• Haugland, Lamarche, and Ramage LLC

  • Community/Behavioral Health Agency
  • Columbus, OH
  • NPI 1346678190
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1165190400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1670976000000",
    "number": "1801954920",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "455 SHAWNEE LN",
            "city": "CHILLICOTHE",
            "state": "OH",
            "postal_code": "456014145",
            "telephone_number": "740-779-4888",
            "fax_number": "740-779-4898"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "455 SHAWNEE LN",
            "city": "CHILLICOTHE",
            "state": "OH",
            "postal_code": "456014145",
            "telephone_number": "740-779-4888",
            "fax_number": "740-779-4898"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GONTKOVSKY",
        "first_name": "SAMUEL",
        "middle_name": "THOMAS",
        "name_prefix": "Dr.",
        "credential": "PSY.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-04",
        "last_updated": "2022-12-14",
        "certification_date": "2022-12-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "WI",
            "license": "3446-57",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NE",
            "license": "723",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MS",
            "license": "42692",
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "OH",
            "license": "7285",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0108112",
            "state": "OH"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "adena.counseling@adena.medicity.net",
            "affiliation": "N",
            "address_1": "455 Shawnee Ln",
            "city": "Chillicothe",
            "state": "OH",
            "country_code": "US",
            "postal_code": "456014145",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Clinical Psychologist in Chillicothe, OH
• Providers in Chillicothe, OH by specialty
• Clinical Psychologist in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.