Provider Demographics
NPI:1932185477
Name:ENGELSTATTER, GEROLF (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEROLF
Middle Name:
Last Name:ENGELSTATTER
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 1:1703 COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6006
Mailing Address - Country:US
Mailing Address - Phone:910-347-3010
Mailing Address - Fax:910-347-3201
Practice Address - Street 1:1703 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6006
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:910-347-3201
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1140103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000579Medicaid
NC04581OtherBC/BS
NC2811546Medicare ID - Type Unspecified