Provider Demographics
NPI:1891834305
Name:BOUKLAS, GEORGE JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:JAMES
Last Name:BOUKLAS
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 1:69A GNARLED HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-2026
Mailing Address - Country:US
Mailing Address - Phone:631-751-0092
Mailing Address - Fax:631-689-6201
Practice Address - Street 1:69A GNARLED HOLLOW RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2026
Practice Address - Country:US
Practice Address - Phone:631-751-0092
Practice Address - Fax:631-689-6201
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011248103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01338949Medicaid
NY01338949Medicaid