Healthcare Provider Details

I. General information

NPI: 1568795748
Provider Name (Legal Business Name): GUDRUN MATILDE OPITZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2009
Last Update Date: 09/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 CENTRAL PARK W 1B
NEW YORK NY
10025-6547
US

IV. Provider business mailing address

350 CENTRAL PARK W 1B
NEW YORK NY
10025-6547
US

V. Phone/Fax

Practice location:
  • Phone: 212-844-9604
  • Fax: 212-543-5163
Mailing address:
  • Phone: 212-844-9604
  • Fax: 212-543-5163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number017297
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number017297
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number017297
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number017297
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: