Healthcare Provider Details

I. General information

NPI: 1720719081
Provider Name (Legal Business Name): MICHAEL GAYLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2022
Last Update Date: 06/18/2022
Certification Date: 06/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 CONE PL
LEEDS NY
12451-1503
US

IV. Provider business mailing address

104 CONE PL
LEEDS NY
12451-1503
US

V. Phone/Fax

Practice location:
  • Phone: 518-965-8473
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002742
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: