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NPI Code Detail

MEDICARE: NIKKI A GUSTAVSON PSY.D.

MEDICARE: NIKKI A GUSTAVSON PSY.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical Psychologist019182NY

General Provider Information

NPI Number : 1174122816
Entity Type Code : Individual
Provider Name (Legal Business Name) : NIKKI A GUSTAVSON PSY.D.
Provider Business Mailing Address
First Line : 275 BROADHOLLOW RD STE 120
Second Line :
City : MELVILLE
State : NY
Zip : 11747-4863
Country : US
Telephone Number : 845-279-5908
Fax Number : 845-622-5055
Provider Business Practice Location Address
First Line : 275 BROADHOLLOW RD STE 120
Second Line :
City : MELVILLE
State : NY
Zip : 11747-4863
Country : US
Telephone Number : 845-279-5908
Fax Number : 845-622-5055
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/23/2020
Last Update Date : 06/02/2026

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