Provider Demographics
NPI:1316728868
Name:HADDOCK, KERRY (PSYD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:HADDOCK
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 1:260 MAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1738
Mailing Address - Country:US
Mailing Address - Phone:631-464-0260
Mailing Address - Fax:
Practice Address - Street 1:260 MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-1738
Practice Address - Country:US
Practice Address - Phone:631-464-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025768-01103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist