Provider Demographics
NPI:1104949114
Name:GERETY, EDY (PSYD)
Entity type:Individual
Prefix:DR
First Name:EDY
Middle Name:
Last Name:GERETY
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 1:1729 E PINE AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4456
Mailing Address - Country:US
Mailing Address - Phone:310-622-5835
Mailing Address - Fax:
Practice Address - Street 1:1729 E PINE AVE APT 5
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4456
Practice Address - Country:US
Practice Address - Phone:310-622-5835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19514103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical