MEDICARE: GABRIELLE FIDIS LCAT, RDT

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
1	101200000X	Drama Therapist	002944	NY

General Provider Information

NPI Number	:	1447015011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GABRIELLE FIDIS LCAT, RDT

Provider Business Mailing Address
First Line	:	3418 44TH ST APT 1F
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11101-1252
Country	:	US
Telephone Number	:	516-319-2881
Fax Number	:

Provider Business Practice Location Address
First Line	:	3418 44TH ST APT 1F
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11101-1252
Country	:	US
Telephone Number	:	516-319-2881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2024
Last Update Date	:	02/14/2024

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