MEDICARE: DR. PHYLLIS GILDSTON PH.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
1	101YM0800X	Mental Health Counselor	000296-1	NY
2	106H00000X	Marriage & Family Therapist	000340-1	NY
3	231H00000X	Audiologist	000080-1	NY
4	235Z00000X	Speech-Language Pathologist	000225-1	NY

General Provider Information

NPI Number	:	1669663050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHYLLIS GILDSTON PH.D.

Provider Business Mailing Address
First Line	:	275 MIDDLE NECK RD
Second Line	:	SUITE B-6
City	:	GREAT NECK
State	:	NY
Zip	:	11023-1925
Country	:	US
Telephone Number	:	516-482-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	275 MIDDLE NECK RD
Second Line	:	SUITE B-6
City	:	GREAT NECK
State	:	NY
Zip	:	11023-1925
Country	:	US
Telephone Number	:	516-482-4444
Fax Number	:

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

Provider Enumeration Date	:	08/09/2007
Last Update Date	:	08/09/2007

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