Provider Demographics
NPI:1780981993
Name:WEBER, SERGIO J (PHD)
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:J
Last Name:WEBER
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 1:1495 ROTH RD
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1828
Mailing Address - Country:US
Mailing Address - Phone:516-785-0114
Mailing Address - Fax:
Practice Address - Street 1:1495 ROTH RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1828
Practice Address - Country:US
Practice Address - Phone:516-785-0114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010277-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY680015258OtherRAILROAD MEDICARE
NY0004040OtherMEDICARE GHI
NY02265727Medicaid