Provider Demographics
NPI:1245498856
Name:GREGORY, DAVID ABRAHAM (LCSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ABRAHAM
Last Name:GREGORY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4567 CROSSROADS PARK DRIVE
Mailing Address - Street 2:SENIOR CONNECTIONS PSYCHOLOGICAL SERVICES OF NEW YORK P
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:270 RIVERSIDE DRIVE #201
Practice Address - Street 2:SENIOR CONNECTIONS PSYCHOLOGICAL SERVICES OF NEW YORK P
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2741
Practice Address - Country:US
Practice Address - Phone:845-781-6061
Practice Address - Fax:607-648-8717
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068419-1101YM0800X
NY0776251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03486293Medicaid
NY03486293Medicaid