Provider Demographics
NPI:1053425702
Name:MCDOUGALL, GERARDA (LCSW)
Entity type:Individual
Prefix:
First Name:GERARDA
Middle Name:
Last Name:MCDOUGALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 N BROADWAY STE PH1
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2025
Mailing Address - Country:US
Mailing Address - Phone:516-526-5993
Mailing Address - Fax:
Practice Address - Street 1:366 N BROADWAY STE PH1
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2025
Practice Address - Country:US
Practice Address - Phone:516-754-4158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR046340-11041C0700X
NYR-046340-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0485ADMedicare PIN