Provider Demographics
NPI:1235428145
Name:ELIAS, DAMIAN MICHAEL GERLACH (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAMIAN
Middle Name:MICHAEL GERLACH
Last Name:ELIAS
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 1:582 5TH ST
Mailing Address - Street 2:APT #2B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3534
Mailing Address - Country:US
Mailing Address - Phone:215-327-2504
Mailing Address - Fax:
Practice Address - Street 1:1140 BROADWAY
Practice Address - Street 2:STE 204
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-7504
Practice Address - Country:US
Practice Address - Phone:215-327-2504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NY019554103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY019554OtherNYS LICENSE NUMBER