Provider Demographics
NPI:1811086028
Name:DAVIS, GERALENE (PHD)
Entity type:Individual
Prefix:
First Name:GERALENE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
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:PO BOX 1517 MURRAY HILL STATION
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10156-1517
Mailing Address - Country:US
Mailing Address - Phone:718-337-1796
Mailing Address - Fax:718-337-1796
Practice Address - Street 1:5110 12TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3424
Practice Address - Country:US
Practice Address - Phone:800-275-3243
Practice Address - Fax:800-275-3671
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006924-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV30713Medicare ID - Type UnspecifiedMEDICARE