Provider Demographics
NPI:1942367511
Name:KINGSLEY, GARY JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
Last Name:KINGSLEY
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 1:646 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2235
Mailing Address - Country:US
Mailing Address - Phone:631-473-5404
Mailing Address - Fax:631-473-5404
Practice Address - Street 1:646 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2235
Practice Address - Country:US
Practice Address - Phone:631-473-5404
Practice Address - Fax:631-473-5404
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09551-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist