Provider Demographics
NPI:1174296834
Name:GUTLEIZER, SHOLOM
Entity Type:Individual
Prefix:
First Name:SHOLOM
Middle Name:
Last Name:GUTLEIZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 LEFFERTS AVE APT A5
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1220
Mailing Address - Country:US
Mailing Address - Phone:917-671-8557
Mailing Address - Fax:
Practice Address - Street 1:1117 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-4801
Practice Address - Country:US
Practice Address - Phone:917-671-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-08-11
Deactivation Date:2021-07-28
Deactivation Code:
Reactivation Date:2021-08-11
Provider Licenses
StateLicense IDTaxonomies
NY36193101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)