Healthcare Provider Details

I. General information

NPI: 1013154731
Provider Name (Legal Business Name): CRYSTAL L GAUEN LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2009
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E 176TH ST
BRONX NY
10457-6003
US

IV. Provider business mailing address

216 E 118TH ST APT. 2B
NEW YORK NY
10035-4184
US

V. Phone/Fax

Practice location:
  • Phone: 718-901-6847
  • Fax:
Mailing address:
  • Phone: 917-407-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number001179
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: