Healthcare Provider Details

I. General information

NPI: 1891907358
Provider Name (Legal Business Name): JUDY CHANG GUMMELT PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JUDY P CHANG PSY.D.

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 E 79TH ST 4-1
NEW YORK NY
10075-0150
US

IV. Provider business mailing address

16 E 79TH ST 4-1
NEW YORK NY
10075-0150
US

V. Phone/Fax

Practice location:
  • Phone: 212-861-4783
  • Fax:
Mailing address:
  • Phone: 212-861-4783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number010366-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18086
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1836
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: