=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477993178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY DIGIACOMO PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2013
-----------------------------------------------------
Last Update Date | 10/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 ABBOT RD
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-793-9156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 ABBOT RD
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-793-9156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 021801
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY60632239
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 749032131
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------