Healthcare Provider Details

I. General information

NPI: 1053563429
Provider Name (Legal Business Name): MARIA GAUDIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 NEILL AVE
BRONX NY
10461-1329
US

IV. Provider business mailing address

1089 NEILL AVE
BRONX NY
10461-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-684-3198
  • Fax:
Mailing address:
  • Phone: 718-684-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1205777
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: