Provider Demographics
NPI:1558398321
Name:GAUDETTE, MARC (PH D)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:GAUDETTE
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 420
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4285
Mailing Address - Country:US
Mailing Address - Phone:585-723-7972
Mailing Address - Fax:585-368-3119
Practice Address - Street 1:2655 RIDGEWAY AVE
Practice Address - Street 2:SUITE 420
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4285
Practice Address - Country:US
Practice Address - Phone:585-723-7972
Practice Address - Fax:585-368-3119
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011956103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02307028Medicaid
NYRA0152 - GRP:BA0017Medicare PIN
NYBB6552Medicare PIN
NYBB6552Medicare PIN