Provider Demographics
NPI:1326095191
Name:GERDES-MARTIN, STEPHANIE NICOLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:NICOLE
Last Name:GERDES-MARTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 88TH ST
Mailing Address - Street 2:3G
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-5645
Mailing Address - Country:US
Mailing Address - Phone:212-238-7498
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON STREET
Practice Address - Street 2:GOUVERNEUR HEALTHCARE SERVICES
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:212-238-7498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068974104100000X
NY076195-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400002489Medicare PIN