Provider Demographics
NPI:1902049752
Name:HAGGERTY, GINA MARIE
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 POWELL CT
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-3914
Mailing Address - Country:US
Mailing Address - Phone:631-893-9151
Mailing Address - Fax:631-893-9151
Practice Address - Street 1:64 POWELL CT
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-3914
Practice Address - Country:US
Practice Address - Phone:631-893-9151
Practice Address - Fax:631-893-9151
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
NY001270-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst