Provider Demographics
NPI:1952549032
Name:DREYER, ALICE SAMANTHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:SAMANTHA
Last Name:DREYER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:SAMANTHA
Other - Last Name:THIBODEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:1050 HALLOCK AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1214
Mailing Address - Country:US
Mailing Address - Phone:631-880-1178
Mailing Address - Fax:
Practice Address - Street 1:1050 HALLOCK AVE STE 2
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1214
Practice Address - Country:US
Practice Address - Phone:631-880-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017743103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist