Provider Demographics
NPI:1821121146
Name:GERACE, CHARLES P (L-CSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:P
Last Name:GERACE
Suffix:
Gender:M
Credentials:L-CSW
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:P
Other - Last Name:GERACE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:81 KATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1709
Mailing Address - Country:US
Mailing Address - Phone:631-476-2104
Mailing Address - Fax:
Practice Address - Street 1:1050 HALLOCK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1214
Practice Address - Country:US
Practice Address - Phone:631-930-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073130-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical