Provider Demographics
NPI:1689749384
Name:CIPKALA-GAFFIN, GERALD LEE (PHD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LEE
Last Name:CIPKALA-GAFFIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:GERALD
Other - Middle Name:LEE
Other - Last Name:GAFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2523 MATTERHORN DR
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-7963
Mailing Address - Country:US
Mailing Address - Phone:724-940-2363
Mailing Address - Fax:724-940-2363
Practice Address - Street 1:10475 PERRY HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9274
Practice Address - Country:US
Practice Address - Phone:724-940-2363
Practice Address - Fax:724-940-2363
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006097L103TA0700X, 103TC0700X, 103TC2200X, 103T00000X
OH4793103TA0700X, 103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014761210002Medicaid
OH0160730Medicaid
OHCP15101Medicare PIN
PA181969Medicare PIN
OH0160730Medicaid