Provider Demographics
NPI:1235703174
Name:GONSALVES SOOKDEO, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:GONSALVES SOOKDEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 OCEAN AVE APT A9
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5556
Mailing Address - Country:US
Mailing Address - Phone:347-844-1479
Mailing Address - Fax:
Practice Address - Street 1:3 GREENHILLS RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3905
Practice Address - Country:US
Practice Address - Phone:718-626-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY280013081103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral