Healthcare Provider Details

I. General information

NPI: 1114259405
Provider Name (Legal Business Name): MARYA GWADZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

200 W 15TH ST FIRST FLOOR
NEW YORK NY
10011-6539
US

IV. Provider business mailing address

503 50TH AVE APT 2D
LONG ISLAND CITY NY
11101-5707
US

V. Phone/Fax

Practice location:
  • Phone: 917-863-2125
  • Fax:
Mailing address:
  • Phone: 917-863-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number014551
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: