Healthcare Provider Details

I. General information

NPI: 1003478496
Provider Name (Legal Business Name): MEGAN GELLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 SUTPHIN BLVD
JAMAICA NY
11434-1527
US

IV. Provider business mailing address

11630 SUTPHIN BLVD
JAMAICA NY
11434-1527
US

V. Phone/Fax

Practice location:
  • Phone: 718-322-2500
  • Fax: 718-322-1881
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30549
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: