Provider Demographics
NPI:1124145958
Name:DWYER, GERALD WALTER (LCSW)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:WALTER
Last Name:DWYER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GRANDVIEW TER
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2812
Mailing Address - Country:US
Mailing Address - Phone:718-984-0854
Mailing Address - Fax:718-984-0854
Practice Address - Street 1:4062 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-2409
Practice Address - Country:US
Practice Address - Phone:718-984-0854
Practice Address - Fax:718-984-0854
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0549221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY198504OtherCOMPSYCH CORPORATION
NY0211582Medicaid
NYP2533945OtherOXFORD HEALTH PLAN
NY000100400301OtherHEALTH PLUS
NY62-27456OtherUNITED HEALTHCARE SERVICE
NY132568Other1199EIU NATIONAL BENEFIT
NY198504OtherCOMPSYCH CORPORATION