Provider Demographics
NPI:1417303611
Name:GOULDSBURY, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:GOULDSBURY
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 1:16 FLORENCE DR
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-3008
Mailing Address - Country:US
Mailing Address - Phone:631-478-7507
Mailing Address - Fax:
Practice Address - Street 1:31 E MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-1816
Practice Address - Country:US
Practice Address - Phone:631-723-3362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY30619101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30619OtherOASAS CERTIFICATE