Provider Demographics
NPI:1871710236
Name:YAGODA, GERALD ROBERT (PHD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:ROBERT
Last Name:YAGODA
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 1:9 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-2632
Mailing Address - Country:US
Mailing Address - Phone:631-329-0680
Mailing Address - Fax:631-267-6467
Practice Address - Street 1:9 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-2632
Practice Address - Country:US
Practice Address - Phone:631-329-0680
Practice Address - Fax:631-267-6467
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4132103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6894605OtherGHI
NY137695OtherVALUE OPTIONS