Provider Demographics
NPI:1396040721
Name:GAYLORD, MAXINE C (LCSW, BCD)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:C
Last Name:GAYLORD
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W END AVE
Mailing Address - Street 2:#19B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5719
Mailing Address - Country:US
Mailing Address - Phone:917-399-9117
Mailing Address - Fax:
Practice Address - Street 1:75 MAIDEN LN
Practice Address - Street 2:SUITE # 215
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4810
Practice Address - Country:US
Practice Address - Phone:917-399-9117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-15
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPR-026241OtherLICENSSED CLINICAL SOCIAL WORKER