Provider Demographics
NPI:1518003177
Name:EDELSTEIN, GARY J (LCSW-R)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:EDELSTEIN
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WIMISINK RD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:CT
Mailing Address - Zip Code:06784-1132
Mailing Address - Country:US
Mailing Address - Phone:860-355-2048
Mailing Address - Fax:
Practice Address - Street 1:40 JON BARRETT RD
Practice Address - Street 2:
Practice Address - City:PATTERSON
Practice Address - State:NY
Practice Address - Zip Code:12563-2164
Practice Address - Country:US
Practice Address - Phone:845-878-9078
Practice Address - Fax:845-878-3203
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR027932-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN58761Medicare ID - Type Unspecified