Healthcare Provider Details

I. General information

NPI: 1962898239
Provider Name (Legal Business Name): JACQUELINE O GUDDEMI LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SEAVIEW AVE
STATEN ISLAND NY
10305-3409
US

IV. Provider business mailing address

777 SEAVIEW AVE
STATEN ISLAND NY
10305-3409
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-2463
  • Fax:
Mailing address:
  • Phone: 718-667-2463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number069944
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: