Healthcare Provider Details

I. General information

NPI: 1861150062
Provider Name (Legal Business Name): MARIANA GUDZ MS.SP.ED, MS.ED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2021
Last Update Date: 12/04/2021
Certification Date: 12/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DALE AVE
STATEN ISLAND NY
10306-1918
US

IV. Provider business mailing address

45 DALE AVE
STATEN ISLAND NY
10306-1918
US

V. Phone/Fax

Practice location:
  • Phone: 347-495-5440
  • Fax:
Mailing address:
  • Phone: 347-495-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number3011886
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: