Provider Demographics
NPI:1790825503
Name:GOLOGOR, ETHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:GOLOGOR
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 1:340 E. 93 ST.
Mailing Address - Street 2:APT. 21E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5555
Mailing Address - Country:US
Mailing Address - Phone:212-737-0072
Mailing Address - Fax:
Practice Address - Street 1:340 E. 93 ST
Practice Address - Street 2:21E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5555
Practice Address - Country:US
Practice Address - Phone:212-737-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004698103TC0700X, 103TE1100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY146126OtherVALUE OPTIONS
NY61033707OtherUBH
NY00921811Medicaid
NY0099997OtherGHI-CBP
NY176973OtherMHN
V20351Medicare PIN