Provider Demographics
NPI:1437511029
Name:GEOGHEGAN, KERRI
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:GEOGHEGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-5606
Mailing Address - Country:US
Mailing Address - Phone:631-747-8976
Mailing Address - Fax:
Practice Address - Street 1:155 INDIAN HEAD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2212
Practice Address - Country:US
Practice Address - Phone:631-543-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30983101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30983OtherCERTIFICATE #