1023406626 NPI number — AG CHILD AND ADULT PSYCHOLOGY, P.C.

Table of content: ETHAN GAINOR JACKSON PT, DPT (NPI 1891210456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023406626 NPI number — AG CHILD AND ADULT PSYCHOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AG CHILD AND ADULT PSYCHOLOGY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023406626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 KEEN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11229-6056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S OYSTER BAY RD
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
HICKSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11801-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-818-8383
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GROMOVA
Authorized Official First Name:
ALENA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
718-873-6678

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  0210021 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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