Provider Demographics
NPI:1992724363
Name:KORN, GARY A
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:KORN
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 1:110 ELLIMAN PL
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-2615
Mailing Address - Country:US
Mailing Address - Phone:516-496-2571
Mailing Address - Fax:516-496-2571
Practice Address - Street 1:110 ELLIMAN PL
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-2615
Practice Address - Country:US
Practice Address - Phone:516-496-2571
Practice Address - Fax:516-496-2571
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR#20847101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN42411Medicare PIN