MEDICARE: MR. MICHAEL GENTILE PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	005958	NY

General Provider Information

NPI Number	:	1912981051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL GENTILE PHD

Provider Business Mailing Address
First Line	:	3601 AVENUE T
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4916
Country	:	US
Telephone Number	:	718-998-2533
Fax Number	:	718-376-9115

Provider Business Practice Location Address
First Line	:	3601 AVENUE T
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11234-4916
Country	:	US
Telephone Number	:	718-998-2533
Fax Number	:	718-376-9115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2005
Last Update Date	:	07/08/2007

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