Basic Information
| Provider Information | |||||||||
| NPI: | 1346305042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAGAN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 ACADEMY RD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122083103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184262600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 PINNACLE PL | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122033496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184262600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 005659 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 11578466 | 01 | NY | CAQH PROVIDER ID | OTHER |