MEDICARE: FULL GESTALT

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1518581206
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL GESTALT

Provider Business Mailing Address
First Line	:	5 W 86TH ST APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3663
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 W 86TH ST APT 1B
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10024-3663
Country	:	US
Telephone Number	:	917-215-1629
Fax Number	:

Authorized Official
Title or Position	:	CONSULTANT
Name	:	MICHAEL MEIKSON
Credential	:
Telephone Number	:	917-842-8765

Provider Enumeration Date	:	05/29/2020
Last Update Date	:	05/29/2020

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