Healthcare Provider Details

I. General information

NPI: 1548050255
Provider Name (Legal Business Name): JOLITA LYDIA GUDAITIS MSED; MSM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BLUEBERRY LN
STONY BROOK NY
11790-2515
US

IV. Provider business mailing address

23 BLUEBERRY LN
STONY BROOK NY
11790-2515
US

V. Phone/Fax

Practice location:
  • Phone: 516-313-4885
  • Fax:
Mailing address:
  • Phone: 516-313-4885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1840812
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: