Healthcare Provider Details

I. General information

NPI: 1881097111
Provider Name (Legal Business Name): MICHELLE DIAZ-GAUTREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 02/22/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89-44 164TH ST
JAMAICA NY
11432-6103
US

IV. Provider business mailing address

60 MADISON AVE FL 5
NEW YORK NY
10010-1600
US

V. Phone/Fax

Practice location:
  • Phone: 718-523-2123
  • Fax: 718-523-5833
Mailing address:
  • Phone: 212-545-2409
  • Fax: 646-312-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number092049
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number086893
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: