=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992241780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAIL DEMARCO, PHD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2017
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 RIDGEWOOD RD
-----------------------------------------------------
City | NIANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06357-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-581-0161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 RIDGEWOOD RD
-----------------------------------------------------
City | NIANTIC
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06357-2214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-581-0161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. GAIL ANN DEMARCO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 860-581-0161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 002381
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------