Healthcare Provider Details

I. General information

NPI: 1629378062
Provider Name (Legal Business Name): STEPHANIE GUMAER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N AURORA ST
ITHACA NY
14850-4345
US

IV. Provider business mailing address

201 E GREEN ST
ITHACA NY
14850-5635
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-2811
  • Fax: 607-273-1170
Mailing address:
  • Phone: 607-274-6200
  • Fax: 607-274-6316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number077583-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number087424-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number077583-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: