Provider Demographics
NPI:1770625980
Name:GASPER, PEGGY (PSYD)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:GASPER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1322
Mailing Address - Country:US
Mailing Address - Phone:631-563-3162
Mailing Address - Fax:631-563-3185
Practice Address - Street 1:1563 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1322
Practice Address - Country:US
Practice Address - Phone:631-563-3162
Practice Address - Fax:631-563-3185
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014872-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVL8731Medicare ID - Type UnspecifiedPSYCHOLOGIST