Provider Demographics
NPI:1396331658
Name:KERRIGAN, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KERRIGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153A LAKE SHORE ROAD
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779
Mailing Address - Country:US
Mailing Address - Phone:631-306-5748
Mailing Address - Fax:631-237-3480
Practice Address - Street 1:153A LAKE SHORE ROAD
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779
Practice Address - Country:US
Practice Address - Phone:631-306-5748
Practice Address - Fax:631-237-3480
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106395104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker