Healthcare Provider Details

I. General information

NPI: 1568996247
Provider Name (Legal Business Name): STEPHANIE GBAGUIDI BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BEACH CHANNEL DR
FAR ROCKAWAY NY
11694-2818
US

IV. Provider business mailing address

14620 232ND ST
SPRINGFIELD GARDENS NY
11413-4443
US

V. Phone/Fax

Practice location:
  • Phone: 718-734-3290
  • Fax:
Mailing address:
  • Phone: 201-344-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: