Provider Demographics
NPI:1033292495
Name:GJERTSEN, RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:GJERTSEN
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:PO BOX 1564
Mailing Address - Street 2:
Mailing Address - City:HIGHTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-8864
Mailing Address - Country:US
Mailing Address - Phone:732-549-7272
Mailing Address - Fax:609-426-0344
Practice Address - Street 1:247 MAIN ST
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2727
Practice Address - Country:US
Practice Address - Phone:732-549-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2870103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0090476Medicaid
NJ0090476Medicaid