Provider Demographics
NPI:1871673715
Name:KANE, GERALD STEPHEN (PHD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:STEPHEN
Last Name:KANE
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 1:112 SOUTH COUNTRY ROAD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713
Mailing Address - Country:US
Mailing Address - Phone:631-776-2410
Mailing Address - Fax:631-776-2409
Practice Address - Street 1:112 SOUTH COUNTRY ROAD
Practice Address - Street 2:SUITE 116
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713
Practice Address - Country:US
Practice Address - Phone:631-776-2410
Practice Address - Fax:631-776-2409
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0083351103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00888624Medicaid
NY00888624Medicaid