Provider Demographics
NPI:1023136231
Name:DAYBOCH, MARK LAWRENCE (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAWRENCE
Last Name:DAYBOCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 FIFTY ACRE RD S
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2034
Mailing Address - Country:US
Mailing Address - Phone:631-979-9294
Mailing Address - Fax:
Practice Address - Street 1:119 FIFTY ACRE RD S
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2034
Practice Address - Country:US
Practice Address - Phone:631-979-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009516-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02012224Medicaid
NY02012224Medicaid