Healthcare Provider Details

I. General information

NPI: 1881101491
Provider Name (Legal Business Name): JEFFERY DALE GEPHART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 MAIN ST
LE ROY NY
14482-1444
US

IV. Provider business mailing address

71 MAIN ST
LE ROY NY
14482-1444
US

V. Phone/Fax

Practice location:
  • Phone: 585-502-6025
  • Fax:
Mailing address:
  • Phone: 585-502-6025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number119914
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: