Provider Demographics
NPI:1992173884
Name:STEFANATOS, GERRY (DPHIL)
Entity type:Individual
Prefix:
First Name:GERRY
Middle Name:
Last Name:STEFANATOS
Suffix:
Gender:M
Credentials:DPHIL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7948 MONTGOMERY AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2644
Mailing Address - Country:US
Mailing Address - Phone:215-964-0756
Mailing Address - Fax:
Practice Address - Street 1:7948 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2644
Practice Address - Country:US
Practice Address - Phone:215-964-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005335L103G00000X, 103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities