Provider Demographics
NPI:1427598523
Name:GENTILE, SUSAN
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:GENTILE
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 1:393 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5640
Mailing Address - Country:US
Mailing Address - Phone:631-968-1220
Mailing Address - Fax:
Practice Address - Street 1:393 BROOK AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5640
Practice Address - Country:US
Practice Address - Phone:631-968-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017609-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist