Provider Demographics
NPI:1316033780
Name:ANDERSON, GREGGORY T (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGGORY
Middle Name:T
Last Name:ANDERSON
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 1:4 WALNUT STREET
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727
Mailing Address - Country:US
Mailing Address - Phone:631-331-8765
Mailing Address - Fax:631-331-8765
Practice Address - Street 1:4 WALNUT STREET
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727
Practice Address - Country:US
Practice Address - Phone:631-331-8765
Practice Address - Fax:631-331-8765
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010939103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
V6B271Medicare ID - Type Unspecified